Children's Fund

Baroness Andrews: asked Her Majesty's Government:
	What progress they have made on policy for the Children's Fund.

Baroness Ashton of Upholland: My Lords, I am pleased to report that we are making good progress on the Children's Fund. The first wave of areas, which includes some of the most deprived communities in England, is beginning to implement increased and better co-ordinated services for children at risk of social exclusion. Second-wave areas have now submitted their proposals, and we are on course for the Children's Fund to reach all parts of England by 2003-04.

Baroness Andrews: My Lords, I am grateful to the Minister for that helpful Answer. It is good to know that the Children's Fund is beginning to reach the children at risk for whom it was intended.
	My concern is that services for disadvantaged children must be carefully co-ordinated. I would be grateful if the Minister could say what contribution the Children's Fund is making to a more coherent provision. Is the Children and Young People's Unit beginning to make progress in joining up services?

Baroness Ashton of Upholland: My Lords, the Children and Young People's Unit is leading the development of an overarching strategy for children and young people. The unit has consulted widely on a document setting out, for the first time, our vision for all children in the country. The overarching strategy sets out that vision and the principles that, we believe, should apply to all government services. It proposes six key outcomes: health and well-being; achievement and enjoyment; participation and citizenship; protection; responsibility; and inclusion.

Baroness Walmsley: My Lords, does the Minister agree that children in the age range covered by the Children's Fund—5 to 13—and younger children are most vulnerable to physical abuse? How much of the Children's Fund has gone—and is intended to go—into parenting education, including the teaching of disciplining strategies other than physical abuse, so that the repetitive cycle of abuse can be broken?

Baroness Ashton of Upholland: My Lords, the proposals for the Children's Fund are worked out by local partnerships, as the noble Baroness will know. As for the way in which the money is distributed, it is for local partnerships to come together and build on existing services to develop the strategies that are most applicable to their communities. I cannot give the noble Baroness details of a specific amount of money, but I can point her to the way in which partnerships are developing services to ensure that children are less vulnerable.
	The process is geared towards protecting children, by recognising when children are about to be at risk and intervening with children and their families as early as possible, to make sure that they remain safe.

Baroness Blatch: My Lords, does the Minister agree that a great deal of the money—£450 million over three years—is being dissipated by the bureaucracy in the bidding process for securing money at local level? That £450 million is yet more money that is being held back at the centre and not going in at school level.

Baroness Ashton of Upholland: My Lords, the figure that I have is £380 million, available over three years. That money is available to the partnerships, and those partnerships will involve the work that goes on in schools. I disagree with the noble Baroness's claim that the money is being used in a way other than being given to schools.
	It is important that the money that is built into the services is used to bring together health, social care and education services. For the children concerned, it is crucial that we have integration, early intervention and early recognition. That is a fundamental part of what the Children's Fund is attempting to do. The money is reaching the partnerships; they are coming forward in three waves, and money has gone out, in order to ensure that we achieve the fund's objectives.

Baroness Pitkeathley: My Lords, can the Minister say what use is made of the Children's Fund by children with disabilities and their families? I am sure that she will agree that they are a particularly disadvantaged group.

Baroness Ashton of Upholland: My Lords, I am happy to do so. Children's Fund partnerships are required to carry out an analysis of the need for and gaps in preventive services for children in their area. It must focus on children who are at risk of social exclusion. I understand that a substantial number has identified children with disabilities as a particular priority group in the development of Children's Fund work. There are examples of that in Bristol, Bradford and Birmingham.
	Among the services that are being developed are services that are designed to provide additional support directly in schools—that is also relevant to the question asked by the noble Baroness, Lady Blatch—as well as improving access to leisure and cultural activities, additional family support and information services.

Lord Northbourne: My Lords, I may have missed something, in which case I apologise, but can the Minister say how many partnerships are now in operation and how much money has, so far, been distributed to the partnerships or through them?

Baroness Ashton of Upholland: My Lords, the noble Lord has not missed anything; I had not given those figures. There are 40 partnerships in operation in the first wave. We plan to cover all local authority areas by 2003-04. The average allocation is about £1 million. The largest allocation has been given to Birmingham, which has received about £6 million.

Baroness Massey of Darwen: My Lords, can my noble friend the Minister say whether young people have been consulted, as part of the consultation process for partnerships?

Baroness Ashton of Upholland: My Lords, young people and children have been involved in several ways. Some partnerships have employed participation workers specifically to make sure that they work with children. Other ways have been developed, including fun days for children, festivals, theatre groups and music and talent shows. In some areas, young people are directly involved in steering groups. In some cases, young people have been included in the process of recruiting staff. Young people are involved in various ways.

Disruptive Pupils

Baroness Sharp of Guildford: asked Her Majesty's Government:
	Why they have reversed their previous policy of seeking to minimise the exclusion from school of disruptive pupils.

Baroness Ashton of Upholland: My Lords, we have not reversed our policy on exclusions. We no longer have targets for permanent exclusions, but our revised draft guidance restates that, in most cases, before excluding a pupil, a range of alternative strategies should have been tried. However, some incidents may be so serious that permanent exclusion may be appropriate for a first or one-off offence. The new guidance helps to ensure that a balanced approach is taken on this issue.

Baroness Sharp of Guildford: My Lords, I thank the Minister for her reply and am reassured by what she had to say. Does she agree that, at a time when there is concern about rising street crime, it is extremely important that we make sure that young people who are excluded from school—who often come from deeply disturbed backgrounds—are given the chance to have full-time schooling and are not just put into units where they are, perhaps, given only two or three hours' education a week?

Baroness Ashton of Upholland: My Lords, I agree entirely. We must strike a balance between ensuring that children who can be educated in mainstream education are educated in that way and recognising that, for some children, that is impossible. From September, we will work towards the position in which full-time education will be provided for all children who are excluded. The most important part of the strategy, in many ways, is preventing children getting to the stage at which they are excluded.

Lord Elton: My Lords, the Minister said that, in the autumn, we would be working towards a position where we would get all children who are excluded into full-time education. I thought that we had been working towards that for some years. Can she tell us what effective steps have already been taken and what proportion of excluded children are still free to roam the streets without supervision?

Baroness Ashton of Upholland: My Lords, let me make it clear that by September 2002 we expect all children who have been excluded to be in full-time education. We have made that commitment. We are working with local education authorities to ensure that they have the right kind of provision. Noble Lords will be aware that for some children the appropriate provision will be pupil referral units, with the anticipation that children will move back into full-time education. For others it may be simply a different school, with additional support. For yet others, it may the provision of other kinds of educational support. It is a broad range. I did not wish to give the impression that we have not arrived at that point, but rather that we are ensuring that we have in place the breadth of provision that is needed.

Baroness Blatch: My Lords, does the noble Baroness agree—from what I know of the noble Baroness, I am sure she will agree—that a particular problem with regard to disruption in the classroom is that occasioned by young people with autistic spectrum disorder? That very often results in disruption in the classroom. What is really needed is more screening and earlier intervention so that such children are not simply dubbed as disruptive and then left to the devices of a pupil referral unit.

Baroness Ashton of Upholland: My Lords, I could not agree more with the noble Baroness. It is absolutely right and proper to ensure that children with special educational needs are identified early, that support is provided for them within the classroom and that the right kind of support is provided for teachers so that they understand the needs of such children. We also need to ensure that, by working together, those children can enjoy a happy and fulfilling life at school and thus are able to remain in mainstream schooling, where that is appropriate for them, throughout their education.

Lord Dormand of Easington: My Lords, is my noble friend aware that one of the most difficult problems, if not the most difficult problem, for teachers is that of dealing with disruptive children? It may well be—I am sure my noble friend will agree—that exclusion should be used in certain circumstances and for a certain time. Is any research being done and training given to overcome the increasingly difficult problem of dealing with disruptive children?

Baroness Ashton of Upholland: My Lords, we are very concerned about disruption in schools. Within the department I chair a group which is looking specifically at behavioural issues. We are working with colleagues across departments, particularly those in educational psychology and those from the Child and Adolescent Mental Health Unit at the Department of Health, in order to achieve solutions.
	It is worth saying to my noble friend that we are also interested in looking at those schools which have been very successful at ensuring that children are not excluded through working with, for example, learning support mentors and establishing learning support units on site. We are developing a range of strategies which will enable our children to be in mainstream schools, while also supporting our teachers, for whom this is a serious issue.

Lord Pilkington of Oxenford: My Lords, in view of recent press reports, has the Minister paid attention to what teachers have to face in the classroom when dealing with disruptive children? There are times when children need to be referred to pupil referral units, but I gather that the units in East London are small. I speak from anecdotal evidence, but I understand that in Hackney and Tower Hamlets, there are hardly any such units. How are teachers to deal with pupils who curse and defy them when all they can do is to refer them for counselling and so forth? Attention must be given to providing sufficient referral units, and after that of course bringing children back into the mainstream. Can the Minister tell the House what attention is being given to the provision of referral units?

Baroness Ashton of Upholland: My Lords, I am grateful to the noble Lord for his questions. We are ensuring that we have on the ground in local education authorities the right breadth of provision and support for students. Pupil referral units are an important part of that provision. We are ensuring, through the allocation of resources, that we do have in place the right level of support for young people.
	However, this problem also concerns preventive measures in the classroom. It is about ensuring that our children receive the right kind of support and, I would argue, it is about parental involvement. We must ensure that parents work with schools, that they send the right messages to their young children about the role of schools, that they work with teachers and are seen to be supportive and respectful of schools.

Baroness Walmsley: My Lords, can the Minister confirm that learning support units in schools, to which she referred in an earlier answer, often provide an easier route back into the mainstream after a temporary exclusion has been, it is hoped, successful? Can she tell the House a little about the balance between the two? Are learning support units always the first recourse, with exclusion units being the last recourse for children who cause disruption in the classroom?

Baroness Ashton of Upholland: My Lords, the answer to the noble Baroness's question depends partly on what resources a particular local education authority has put in place. We believe that learning support units are making a big difference and we are particularly interested in their work in inner-city schools. However, they are not yet in place everywhere and so they will not be available for every school.
	However, decisions also depend on the reason for the exclusion. I think that noble Lords would agree that, wherever possible, we want those children who come out of mainstream education and into a unit to be able to return to school in due course. That also applies to special schools when considering behavioural issues in children. Among their criteria for success is the number of children they are able to reintegrate into mainstream education.

Baroness Carnegy of Lour: My Lords, the noble Baroness has told us that the Government have abandoned a system of targets in relation to children excluded from school. Does the Minister agree that that system has proved totally unsuitable? In certain areas of activity, targets can be really very damaging to the work of professionals on the ground. Will she agree to bring to the attention of her right honourable friend that there are other areas in education where targets might well be damaging and, indeed, other areas in government, such as the National Health Service? It is only too easy to set targets and think that one is managing from the centre, but they can do a great deal of damage.

Baroness Ashton of Upholland: My Lords, noble Lords will know that I have been on the receiving end of many targets in the course of my professional life. I have to say that targets play an important role in ensuring not least that the Government do what they say they will do. Noble Lords in this House will certainly ensure that the Government report back on the targets they have set. Indeed, for many organisations, including schools and—if I may trespass into another area of public sector life—the health service, it is important that we set ourselves the right kind of targets. With regard to education, we are discussing here the one chance that young people have to receive a good education. I think that we should set targets for ourselves.

NHS: Latex-related Allergies

Baroness Gibson of Market Rasen: asked Her Majesty's Government:
	How much the National Health Service has paid out in early retirement costs and compensation payments for those forced to leave their jobs due to latex-related allergies.

Lord Hunt of Kings Heath: My Lords, information on the costs of early retirement or compensation payments due to specific medical conditions is not available centrally, although the extra cost of retirement through ill health in the NHS has been calculated at £60,000 per employee retired. Of the 4,482 staff who left the service on grounds of ill health during 2000-01, some 1.7 per cent were due to skin allergies, some of which may have been attributable to latex.

Baroness Gibson of Market Rasen: My Lords, I thank my noble friend for that reply. Is he aware that many workers in the health service are extremely worried about latex allergies? It is not only a question of latex gloves, but also of the latex used in many other areas of a hospital. Does he agree that, since alternative materials are available—for example, for latex gloves—it would be wise for hospitals to provide such alternatives for those workers who are worried about exposure to latex? To inform the House, I should say that latex can cause skin disease, but it can also trigger conditions such as asthma and other respiratory problems.

Lord Hunt of Kings Heath: My Lords, my noble friend is right to suggest that latex is a sensitiser and that it can pose some risk to NHS staff. However, that risk is posed to only a minority. I should also say to my noble friend that some of the alternatives to latex products also contain chemicals which can cause allergic reactions in both staff and patients. The European Commission working group on latex is confident that the current directive provides sufficient protection for patients and staff if it is fully and properly implemented. However, in the light of the Question put by my noble friend and the concerns that she has expressed, the Government are announcing today their intention to reissue guidance to the NHS, thus drawing employers' attention to the problem and to the alternatives to latex that are now available. The guidance stresses the need for staff and management to work together to assess the risks in each case.

Lord Clement-Jones: My Lords, the Minister has talked about guidance, but what steps are being taken by the NHS to centrally source supplies of low-allergy products?

Lord Hunt of Kings Heath: My Lords, I am glad that the noble Lord has recognised the need for some central action in the health service. A central purchasing agency making decisions at central government level provides the option for the NHS to enter individual contracts. Part of the role of the NHS Purchasing and Supply Agency is to ensure that alternatives to latex products are made available.

Baroness Pitkeathley: My Lords, will my noble friend ensure that when the alternatives are available they will be offered also to patients' visitors? In cases where people are being barrier nursed, visitors have to put on gloves and aprons.

Lord Hunt of Kings Heath: My Lords, that is a very useful suggestion. It is one of the considerations that local employers should take into account when implementing the guidance that we issue to the NHS and in developing a risk assessment strategy.

Baroness Trumpington: My Lords, can the Minister say what kinds of products contain latex? I always thought it existed in corsets.

Lord Hunt of Kings Heath: My Lords, the noble Baroness will know more about that than I do. Such products include surgical gloves, urological sheaths, and various instruments and products used within the health service.

Cash Machines in Rural Post Offices

Baroness Miller of Hendon: asked Her Majesty's Government:
	What is their reaction to the reported proposal to impose a charge of £1.25 for the use of cash machines in rural post offices; and whether this proposal was discussed with Ministers at any stage.

Lord Sainsbury of Turville: My Lords, Post Office Limited is undertaking a programme of cash machine installation with a view to installing 3,000 machines at post offices by the end of 2002. These machines are being provided as an additional service available at some post offices to enable customers to withdraw money from their bank accounts. Wherever possible, the Post Office seeks to arrange for cash machine transactions at post offices to be free of charge. However, in some locations it would not be financially viable to install a machine without a charge being made.
	This programme is separate from arrangements for universal banking services, which will enable all those who wish to do so to continue to be able to collect their benefits in cash at post offices. Decisions relating to cash machines at post offices are a commercial matter for Post Office Limited.

Baroness Miller of Hendon: My Lords, could the consideration of making charges for the use of cash machines in some post offices have been part of a transaction to sell off a major part of the Post Office—a transaction which has recently fallen through? Can the Minister tell the House whether or not there have been recent negotiations to sell off a major part of the Post Office to an overseas buyer? A "yes" or "no" answer will suffice.

Lord Sainsbury of Turville: My Lords, the supplementary question is rather different from the Question on the Order Paper. I have heard of no such suggestion. If one looks at the financing of the rural postal network, not many people would be in the business of buying it.

Baroness Greengross: My Lords, does the Minister agree that some of our poorest citizens live in rural areas and that many of our rural post offices and sub-post offices are disappearing? If you are able to draw out only £10 or £20 at a time, £1.25 in charges is a substantial amount. Elderly and disabled people cannot always get to the nearest supermarket in order to benefit from cash-back schemes.

Lord Sainsbury of Turville: My Lords, I had hoped that I had made the point that this is an additional service. As is common across the whole of the commercial world, where there is a large through-put of people the service is provided free. But where it cannot be justified on that basis, charges are made. In such circumstances, part of the charge will go to the postmaster or postmistress. It is an additional service which can only add to customer facilities. In that sense, it is a commercial decision for the Post Office to take.

Lord Razzall: My Lords, notwithstanding the announcement that he made last year, to a fanfare of musical trumpets, of the subsidy proposals to help rural post offices, does the Minister accept that the deterioration in the rural post office network has continued rapidly since that announcement? Does he further accept that unless the Government's proposals are accelerated there will hardly be a rural postal network left?

Lord Sainsbury of Turville: My Lords, the situation is not as the noble Lord suggests. There has been a slowing down of the closure of rural post offices, but we should not be too optimistic about that because special factors are involved. As to the question of subsidies, which arose from the PRU report, it was always made clear that they were to deal with the transitional arrangements until 2003 when ACT is due to come in.

Earl Ferrers: My Lords, does not the Minister think it slightly unfair that post offices which have a relatively large through-put will not need to charge anything, and yet post offices in the rural areas, which are more necessary but have fewer people to look after, will nevertheless charge? One would have thought that it is those people who should not be charged.

Lord Sainsbury of Turville: My Lords, it is an unfortunate fact of life that in many commercial transactions where there is a small through-put the charges are higher. This is a commercial facility provided by the Post Office. It is common across the country that where there is a small through-put for cash machines which are provided on, essentially, a convenience basis, charges have to be made. Otherwise, there would be no service at all.

Lord Clarke of Hampstead: My Lords—

Lord Swinfen: My Lords—

Lord Livsey of Talgarth: My Lords—

Lord Williams of Mostyn: My Lords, it is the turn of the government Benches.

Lord Clarke of Hampstead: My Lords, before I ask my question, I should like to place on record my delight that my noble friend has given an unequivocal answer to the suggestion that a part of the Post Office was going to be sold off to a foreign competitor. It was a rumour that was going around last weekend and I am delighted that he has been able to say that no such negotiations were known to him. I am also pleased that we have not yet heard the dreaded word "Consignia".
	In view of the repeated assurances from the Government that people will be able to get their benefits paid in cash through the sub-post offices, especially in rural areas—it has been repeated many times—can my noble friend assure the House that in no way will people be advised when they go into their rural post offices that these machines are the means of getting their cash?

Lord Sainsbury of Turville: My Lords, I can give that assurance. We remain fully committed to meeting the Prime Minister's clear pledge that those who wish to do so will be able to continue to get their benefits in cash at post offices, in full and without charge.

Lord Swinfen: My Lords, the Post Office operates universal postal charges throughout the whole country. Why can it not do the same with cash machines?

Lord Sainsbury of Turville: My Lords, there is a long tradition of the universal postal service which is written into the latest Post Office Act. That states that a service will be provided across the country under a one-payment system. The provision of cash machines is an additional service which does not have to be provided under the universal postal obligation. It is a commercial transaction which will be operated on a commercial basis.

Lord Livsey of Talgarth: My Lords, is not the imposition of a charge of £1.25 for the use of cash machines a breach of the principle of providing a universal service to all users of the Post Office? This is bringing market forces to bear and breaking the fundamental principle of the service that the Post Office should provide to rural people.

Lord Sainsbury of Turville: My Lords, the Post Office has a universal service obligation in relation essentially to the mail service. That obligation does not extend to all services. I do not believe that it should. If extra services are provided, they are provided on a commercial basis. That is entirely in keeping with what has gone before.

Baroness Blatch: My Lords, the Minister said that the supplementary question of my noble friend on the Front Bench was irrelevant to her Question. But the viability of the Post Office in the future is very relevant, and that is the point made by my noble friend. Can the Minister confirm unequivocally to the House that on which he has been congratulated by the noble Lord, Lord Clarke—that is, that there have been no negotiations whatever with a foreign company—for example, a Dutch company—in recent times that have failed?

Lord Sainsbury of Turville: My Lords, as I said, I came to the House prepared to answer a Question about cash machines. I therefore did not ask or inquire about any negotiations which may or may not have taken place. If I am wrong, I shall obviously make it clear in a future communication to the noble Baroness. But, I repeat, I know of no negotiations which are taking place to sell the post office network, which I assume is the point of the question. I have no indication that any negotiations have ever taken place on that.

Baroness Miller of Hendon: My Lords, I simply said that this may be part of a transaction to sell off the Post Office—which transaction has failed. That was the point that I made recently. I wanted to know whether the Minister could confirm that negotiations were going on to sell a majority share in the Post Office to a company overseas. That was my question.

Lord Sainsbury of Turville: My Lords, I can only repeat what I have said—which I thought was very clear given the extent of my knowledge on this subject. If it is a question of the financial viability of the rural post office network, this particular move can only help, because a part of the fee goes to the post offices themselves.

Baroness O'Cathain: My Lords, does not the Minister know that the whole future of the Post Office is a very live issue and one which, I am sure, concerns all of us in this House? We had a debate on the future of Consignia some six weeks ago. At the end of the debate, because we ran out of time, I asked the Minister whether he would answer in writing the questions that had been raised. I then wrote to him, about three weeks ago. I have still not heard from him. Is it the case that the Minister does not know what is going on in the Post Office, as he has more or less said to my noble friend Lady Miller?

Lord Sainsbury of Turville: My Lords, I apologise if answers to those questions have not been received. I shall immediately make certain that they are answered. However, if noble Lords opposite want to know what negotiations have taken place, or are going to take place, on Consignia, the proper approach would be to table a Question on that matter, and not focus on the subject of cash machines, which is a quite separate issue.

Business

Lord Carter: My Lords, after the Motion standing in the name of my noble friend Lady Ashton of Upholland, my noble friend Lady Symons of Vernham Dean will, with the leave of the House, repeat a Statement that has been made in another place on Zimbabwe. At a convenient moment after 5 p.m. my noble friend Lord Whitty will, with the leave of the House, repeat a Statement that has been made in another place on hunting with dogs.

Education Bill

Baroness Ashton of Upholland: My Lords, I beg to move the Motion standing in my name on the Order Paper.
	Moved, That it be an instruction to the Committee of the Whole House to whom the Education Bill has been committed that they consider the Bill in the following order:
	Clauses 1 to 18, Schedule 1, Clauses 19 to 35, Schedule 2, Clauses 36 to 38, Schedule 3, Clauses 39 to 48, Schedule 4, Clauses 49 to 53, Schedule 5, Clauses 54 to 56, Schedule 6, Clauses 57 to 62, Schedule 7, Clauses 63 to 66, Schedule 8, Clauses 67 and 68, Schedule 9, Clauses 69 to 71, Schedule 10, Clauses 72 to 115, Schedule 11, Clauses 116 to 143, Schedule 12, Clauses 144 to 147, Schedule 13, Clauses 148 to 150, Schedule 14, Clauses 151 to 180, Schedule 15, Clauses 181, Schedule 16, Clauses 182, Schedule 17, Clauses 183 to 188, Schedule 18, Clauses 189 to 192, Schedule 19, Clauses 193 to 199, Schedule 20, Clause 200 to 210, Schedules 21 and 22.—(Baroness Ashton of Upholland.)

Lord Renton: My Lords, while warmly supporting the Motion, perhaps I may express the hope that, for years to come, it will be regarded by those who are responsible for compiling such Motions as a valuable precedent, because it puts into numerical order all the clauses and schedules of this vast Bill—numerical order being the order in which they should be discussed.

Baroness Ashton of Upholland: My Lords, I am extremely grateful to the noble Lord, who has many years of experience to support his remarks.

On Question, Motion agreed to.

Zimbabwe

Baroness Symons of Vernham Dean: My Lords, with the leave of the House, I shall now repeat a Statement on Zimbabwe which has been made by my right honourable friend the Foreign Secretary in another place. The Statement is as follows:
	"With permission, I should like to make a Statement on Zimbabwe's suspension from the Commonwealth.
	"As the House will be aware, a Commonwealth 'troika' consisting of Presidents Mbeki of South Africa and Obasanjo of Nigeria and Prime Minister John Howard of Australia was authorised by the Commonwealth Heads of Government Meeting to review the outcome of the Zimbabwe elections in the light of the Commonwealth observers' report, and to decide on any action.
	"The troika met in London on Tuesday. It had before it the final report of the Commonwealth observers group. This confirmed the findings of the preliminary report which I put before the House in my Statement last Thursday. The group concluded that,
	"the conditions in Zimbabwe did not adequately allow for a free expression of will by the electors".
	"The troika accepted the conclusions in full and decided as a result to suspend Zimbabwe from the councils of the Commonwealth for one year with immediate effect. This issue will be revisited in 12 months' time, having regard to progress in Zimbabwe, based on the Commonwealth Harare principles and reports from the Commonwealth Secretary-General. I am sure the whole House will join me in expressing our appreciation to Presidents Mbeki and Obasanjo and Prime Minister Howard and in expressing our full support for their conclusions.
	"Three months ago, on 20th December, the Commonwealth Ministerial Action Group, of which I was a member, concluded that Zimbabwe was in 'serious and persistent violation' of the Harare principles. It was my view at that stage that Zimbabwe should, then and there, be suspended from the councils of the Commonwealth. I made this case again at CMAG at the end of January, as did my right honourable friend the Prime Minister at CHOGM itself in early March. As the situation in Zimbabwe has deteriorated day by day since December, it follows that we believe that suspension now is fully justified.
	"The Commonwealth depends above all on its moral authority, and on the force of the principles which it codified in Harare itself in 1991. That is why the decision was so important for the Commonwealth as a whole, as well as, of course, for Zimbabwe. And that moral authority is what gives this decision its force.
	"I am in no doubt, from the way in which the Government of Zimbabwe had sought actively to divide the Commonwealth, that they were, and are, profoundly concerned about the international isolation which suspension signals. Tuesday's decision was, therefore, significant in many respects: above all, for the fact that leaders of two key African nations have taken a clear and definitive stand in defence of the Commonwealth's fundamental principles. They have also underlined Africa's commitment to the universal and indivisible principles of democracy and human rights.
	"Suspension is one of the strongest measures the Commonwealth can impose. In the past, countries have only been suspended after the violent overthrow of their elected governments. Zimbabwe's suspension is, therefore, a new departure.
	"Moreover, the Commonwealth's decision is in addition to the targeted sanctions which the European Union, the United States and now Switzerland have imposed against the leaders of ZANU-PF. EU Heads of Government also decided, at the European Council in Barcelona last weekend, to ask Foreign Ministers to look at options for further measures.
	"What has happened in Zimbabwe is a tragedy, imposed on this once prosperous land by Robert Mugabe. Our commitment and that of the Commonwealth to the people of Zimbabwe remains as strong as ever. We have made it clear, since 1997, that the case for land reform in Zimbabwe is very strong, and that we were willing to provide considerable financial support to a land reform process that was transparent, lawful, and which gave priority to the needs of Zimbabweans in overcrowded communal lands. This was a position supported by the international community but rejected by the Mugabe regime.
	"At Abuja, in early September last year, we agreed a pathway for Zimbabwe which would have allowed for a resumption of international aid, including from the United Kingdom, for a programme of sustainable land reform implemented in accordance with the rule of law. Respect for the rule of law, and a return to democratic principles and to sensible economic policies, is the only way back. We remain ready to do all we can to achieve this; and we will continue our programmes of assistance for humanitarian and HIV/AIDS projects. But I must tell the House that in the short term the prospects in Zimbabwe look bleak, underlined by the murders since the election of MDC activists and a commercial farmer, and the fact that the opposition leader Morgan Tsvangirai has now formally been charged with treason.
	"Today, it is all the more urgent that the Government of Zimbabwe commit themselves—as the leaders of the Commonwealth have called for—to healing the divisions in the country and taking the path of genuine reform and national reconciliation. We shall do all that we can to support Presidents Mbeki and Obasanjo, and other African partners, in their efforts to bring stability back to Zimbabwe. This is what the people of Zimbabwe desperately need. Today, the whole of the democratic world supports them in this goal".
	My Lords, that concludes the Statement.

Lord Howell of Guildford: My Lords, the House will be grateful to the noble Baroness for repeating the Statement. We fully share the welcome that she and the Foreign Secretary gave to the conclusions of the Commonwealth troika. We look on those conclusions with a feeling of relief, because if they had gone otherwise the future of the Commonwealth would have been threatened. This is a good moment in an otherwise dark scene. I also share the Minister's desire to pay tribute to Prime Minister Howard and Presidents Obasanjo and Mbeki for having the courage to reach those conclusions, which are said to be already of immense comfort to the brave people of Zimbabwe.
	I am sure that the noble Baroness recognises that the conclusions come too late for the murdered farmer, Terry Ford, and for all the other victims of multiple murders. They come too late for all the farm workers who have been beaten to pulp, too late for the security guards who tried to defend the farms and too late for those Zimbabweans who may be dying of starvation. However, better late than never, I suppose. This is a positive move, without doubt.
	Has the noble Baroness noticed that the US State Department, which usually moves very slowly, has already come out with a strong statement condemning the intimidation and underscoring the illegitimacy of the Mugabe regime? The Statement that we have just heard speaks of the need to do all that we can. Can we have an assurance that there will be real, positive and continuing efforts to form a coalition of democracies to maintain all possible pressures, including the targeted sanctions and other measures—of which we would like some indication of the nature—to ensure that the Mugabe regime remains under pressure until there is agreement for fresh and democratic elections and a new approach? Does she agree that any arrangement that ended up with some kind of sordid deal with Mr Mugabe and anything that legitimised him would be completely unsatisfactory and would continue to threaten the stability of the region?
	What will be done about Mr Tsvangirai, who is mentioned in the Statement? He has now been threatened on trumped-up charges. Can something more be done to prevent this brave man being caught up in the vindictiveness of Mr Mugabe? Do the Government agree that the only discussions that there should be with Mugabe are about the arrangements necessary for new and democratic elections?
	Does the noble Baroness agree that southern Africa will recover from its present dire straits only if justice returns and Mugabe goes? Can she explain how it is that, while Mr Mbeki has courageously supported the conclusions, the South African Parliament apparently recognises the legitimacy of Mr Mugabe, which is a fatal move? Does she recognise that the new African economic partnership—NePAD—will succeed only if the rule of law is properly and firmly restored in southern Africa?
	Can the noble Baroness tell us about the status of our high commission in Harare now that we no longer recognise the legitimacy of the government there? There are brave public servants in our high commission who are doing valuable work. If we are to maintain the humanitarian aid to starving Zimbabweans that will be needed, presumably we shall reinforce the staff there. Will she confirm the status of the commission and whether we shall be enlarging it if we can so that it can help people in their dreadful plight?
	Does the noble Baroness accept that before we do any of that, we need an honest government in Harare—which at the moment we have not got?

Lord Wallace of Saltaire: My Lords, I thank the Government for the Statement. I recognise that the British Government, particularly the noble Baroness, Lady Amos, have worked extremely hard on the issue and that we have limited influence over events in Zimbabwe. The older Members of this House may remember that in 1965 some members of my party were in favour of direct intervention in what was then Rhodesia to prevent a unilateral declaration of independence. I am not aware that any party in this country, even the Conservatives, now proposes such direct intervention. We have limited influence and we have to recognise the need to work with others multilaterally to bring what influence we can to bear. The Government have done well in that task. This is a good day for the Commonwealth. Despite the gloomy predictions from the Conservatives in both Houses of the impending dissolution of the Commonwealth, that prospect is clearly past for the time being.
	How active a role is it intended that the Commonwealth, and in particular the troika, will retain over the coming months as a watching brief, in view of continuing developments in Zimbabwe? In particular, what contingency plans are we making against the prospect of a further deterioration of the Zimbabwean economy in the coming months, with the likelihood of a spillover of refugees into neighbouring countries? That clearly threatens to destabilise the weak economies of southern Africa as a whole. It therefore seems extremely important to work with the neighbours, particularly Mozambique and South Africa, on limiting the damage to the region and, whenever possible, to provide food and aid. We all recognise that we have to contain a possible further collapse of the Zimbabwean economy. In that context, using the Commonwealth and our other multilateral relations, we should continue to promote good governance as the path to development in Africa, in particular through the New Partnership for Africa's Development.
	I have one small partisan point to make. I hope that Anglo-Saxon interventions in promoting good governance in Africa will have an element of humility. A strong comment was made by the US Administration against the idea of fixing elections rather than allowing full democracy. I am conscious that there is sometimes a tendency in this country to demand that other countries should have clear democracies that represent the will of a majority of the people. We do not have that in this country, so perhaps we should be a little more delicate in how we promote standards of democracy higher than our own.

Baroness Symons of Vernham Dean: My Lords, I thank the noble Lords, Lord Howell of Guildford and Lord Wallace of Saltaire, for their responses. Of course, like the noble Lord, Lord Howell, I fully support the views of the troika. That was clear from my right honourable friend's Statement. The noble Lord then said that it came too late for many of the victims of the violence in Zimbabwe. I hope that he does not think that statements in themselves would have stopped the murderous intent of the regime in Zimbabwe. He cannot really believe that more statements would have been enough. Goodness knows, many Statements were made from this Dispatch Box and in another place about the contempt felt for some of the acts of the Zimbabwean Government. To imply that statements in themselves stop murderous intent is not fully to appreciate the position.
	I agree that the statement made by the US State Department is very welcome. I wholeheartedly agree with the noble Lord that honest government in Zimbabwe must be the first priority. As my noble friend has said on many occasions from this Dispatch Box, we must not forget that we are dealing with a sovereign government in Zimbabwe and that we do not have the ability simply to say what should be done there and expect that it will happen as night follows day.
	As both noble Lords have said, we must look to what can happen next. The EU heads of government instructed Foreign Ministers last weekend to consider further what measures can be taken in Zimbabwe, including possible further sanctions. The United States Government, with whom we are in close touch, have said that they will increase sanctions. The Government of New Zealand have said that they are considering imposing sanctions. The Government of Switzerland have already imposed sanctions, which bring them into line with EU sanctions.
	As the Commonwealth troika conclusions made clear, Presidents Mbeki and Obasanjo are working hard on a programme of reconciliation. My right honourable friend the Foreign Secretary will be working to ensure that we give what support we can to Zimbabwe, but, touching on some of the economic questions raised by the noble Lord, Lord Wallace of Saltaire, we shall also look to the IMF and the World Bank to deny the current Zimbabwe regime access to financial support. I am sure that the House would expect no less in terms of sanctions. Given events not so much in the elections but in the run-up to the elections, Mugabe has to be denied what would normally have been his right.
	I do not think that we should be in any doubt about this: it is going to be a very long haul indeed. President Mugabe, as he has demonstrated all too clearly, is determined to cling to power for as long as he can. I hope that I have indicated some of the ways in which Her Majesty's Government are working with others to ensure that that is for as short a time as possible.
	I thank the noble Lord, Lord Wallace of Saltaire, for his comments not only about my right honourable friends in another place but about my colleague in this House, Lady Amos. I wish that she had had the pleasure of making this Statement today. I believe that her endeavour in so many ways—working tirelessly not only in the multilateral forums, one of which she is attending today, in Monterrey, but with many leaders in Africa—has been a key element in bringing us to where we are today. I acknowledge that fully, and I hope that the House will join me in that acknowledgement.
	We have to examine what can be done to distinguish the regime in Zimbabwe from the people of Zimbabwe. As the noble Lord, Lord Wallace of Saltaire, said, Zimbabwe's economic position is appalling: unemployment is currently 60 per cent; inflation is 112 per cent; 35 per cent of the adult population are suffering from HIV/AIDS; and 63 per cent of the population are below the poverty line. All that is occurring in a country that was once a hallmark for prosperity in Africa.
	The suspension of technical aid is one of the sanctions attending Zimbabwe's suspension from the councils of the Commonwealth. That does not involve the suspension of aid which might help in the restoration of democracy. The Commonwealth has drawn that distinction in determining how the suspension will work. It is therefore very much to be hoped that the money for the restoration of democracy will continue to be provided.
	As for the arrest and charging of Mr Tsvangirai, Mr Tsvangirai is now out on bail. We can, however, do only a limited amount in a sovereign state. Although we can monitor events, comment, and bring pressure to bear, as we have already done, the Government of Zimbabwe are continuing to harass leaders of the opposition. They must face the consequences of so doing.
	As for the status of our mission in Harare, the mission remains, and there is no question of withdrawing any of our diplomats. Some 40,000 British citizens are in Zimbabwe and they will need the protection of our mission there more than ever. I hope that all noble Lords send them a strong message of support from this House for the sterling work they are doing.

Lord St John of Bletso: My Lords, I join in welcoming the Statement from the Foreign Secretary, and particularly the fact that it has restored the Commonwealth's credibility. I should like particularly to commend its call for the,
	"Government of Zimbabwe to commit themselves to healing the divisions in the country and taking the path of genuine reform and national reconciliation".
	In that regard, can the Minister outline what measures the troika and Her Majesty's Government are taking to encourage a government of national unity in Zimbabwe?
	I also commend the work of the noble Baroness, Lady Amos. I should, however, like to make one slight alteration to an answer which she gave me in reply to a question I asked her on Tuesday, when I contended that the South African observer mission's report had been politically rigged. The noble Baroness said:
	"the South African parliamentary observers team has dropped its conclusion that the elections were substantially free and fair".—[Official Report, 19/03/02; col. 1230.]
	That is not the case. The South African observers mission has not dropped its contentions, but President Mbeki has dropped certain comments on his website.
	I also revert to the question from the noble Lord, Lord Howell of Guildford, who asked how the Government of Zimbabwe can heal the division when the MDC leader, Morgan Tsvangirai, and the MDC secretary-general, Welshman Ncube, have been formally charged with treason. Moreover, in South Africa, the ANC secretary-general has recently described Morgan Tsvangirai's arrest and charging as "part of the healing process". Surely that is extremely worrying.
	Finally, will the Minister outline what action is being taken to alleviate the severe food shortage, the prospect of mass starvation, and the refugee flight to South Africa which is likely to ensue if the situation is exacerbated?

Baroness Symons of Vernham Dean: My Lords, I thank the noble Lord, Lord St John of Bletso. He is quite right. There are enormous problems in achieving genuine reform— particularly national reconciliation and a government of national unity—when it is so painfully evident that the current government do not want to be a party to anything of the sort, and when they—as the noble Lord rightly reminded us—have not only arrested but charged Morgan Tsvangirai and Welshman Ncube. That is why it is so important that the troika has agreed that work on these issues should be taken forward by Presidents Mbeki and Obasanjo.
	I agree with the noble Lord that, immediately after the election in Zimbabwe, there was some confusion about what was thought by a very small number of people to have been a fair election. When the more substantial reports were properly examined, it was decided that that was not really the case. I remind him of the statement made by the SADC parliamentary forum observer on 13th March:
	"The climate of insecurity obtaining in Zimbabwe since the 2000 parliamentary elections was such that the electoral process could not be said to adequately comply with the Norms and Standards for Elections in the SADC region".
	I think that that is an extremely reassuring statement.
	I fully take the noble Lord's point that we must now be very vigilant. The issue of what is to happen to those arrested and charged with treason—although, as I said, they are out on bail—is another reason for maintaining the full strength of our diplomatic mission in Zimbabwe. We shall be looking for regular reports on those issues.
	The food shortages are causing great worry and concern. Donors are already providing supplementary feeding through the NGOs. Our own Department for International Development has given £4 million of assistance to some 300,000 people. Additionally, last month, DfID made a £6 million contribution to the UNDP's humanitarian assistance and recovery programme for Zimbabwe. I am sure that my right honourable friend the Secretary of State will be keeping that issue under constant review.

Lord Hughes of Woodside: My Lords, I join those who have congratulated the Government on the part they have played in bringing about the troika's decision to suspend Zimbabwe from the Commonwealth. However, no one who is a friend of Zimbabwe takes any pleasure from the suspension as it marks a very serious situation. Does my noble friend agree that the attacks on the Zimbabwe Congress of Trade Unions and on trade unionists trying to exercise a legitimate right to strike concerns everyone, and that the clearly contrived charges brought against the MDC leaders do not help the situation? Does she also, however, agree that sanctions are not the magic bullet which will suddenly transform Zimbabwe from its currently parlous state into a world democracy? Should we not also recall the other part of the troika's statement—that it and the Commonwealth need to remain engaged with Zimbabwe?
	The Opposition spokesman seemed to suggest that in no circumstances should we have any contact with anyone in the Zimbabwe Government. Taking that view to its logical conclusion, should he not be advocating withdrawing Britain's mission, unpalatable as that may be? My noble friend has said that the opposite action is required. Can my noble friend assure the House that, as well as the sanctions which have to be applied, every possible means and method of discussion and dialogue will be used to bring about a resolution as early as possible?

Baroness Symons of Vernham Dean: My Lords, my noble friend draws an important and valuable distinction when he refers to suspending our contacts at an official level with the Government of Zimbabwe while at the same time trying to have proper discussions with those with whom we can do business there. If it is possible in future to have discussions with those in the Mugabe regime who are willing to talk in terms of reconciliation for the future, that would be valuable.
	I agree strongly with my noble friend's remarks regarding the violent attacks on trade unions. The NGO figures suggest that about 73 per cent of the perpetrators of violence appear to be affiliated to ZANU-PF, and 16 per cent are police officers, which is extremely worrying. As your Lordships may know, between 1st January and 28th February this year, 31 people were killed in politically-motivated attacks. Nearly all of those were black Zimbabweans. As we have seen, three members of the MDC have been murdered since the election and one commercial farmer tragically lost his life.
	My noble friend is right. Sanctions are never a magic bullet, but they signify an important measure of outrage and disgust about what has happened in Zimbabwe. It is worth noting what suspension from the councils of the Commonwealth will mean. It means that there will be no participation by the Government of Zimbabwe in intergovernmental meetings, but it does not deprive the people of Zimbabwe of cultural and sporting activities which may be organised by the Commonwealth.

Baroness Park of Monmouth: My Lords, does the Minister agree that it was enormously fortunate and right that the Government increased the number of Commonwealth observers? We have seen what a happy result that gave. However, there is a lesson to be learnt. I entirely share—as we all do—the Minister's admiration for what the mission in Zimbabwe is doing. I hope that we shall not only leave it in place but greatly increase it. The only thing we can do, which no sovereign government can refuse, is to observe and report and be seen to be doing so, particularly now that the laws against the media are being further tightened.
	I hope that it will be possible for there to be an element of observation from the high commission of the dispensing of our humanitarian aid, for instance, so that it is not taken over by ZANU-PF and used to reward its people. My other point is that I hope that we shall persuade the rest of the EU to stay and report. I was rather concerned to see that the Danish mission is withdrawing. The one thing that can be done is to stay and report and be seen to do so.

Baroness Symons of Vernham Dean: My Lords, perhaps in turn I may thank the noble Baroness for her timely intervention on the subject of Commonwealth observers. Your Lordships may remember that, as always, she was forthright in pointing out some of the shortcomings in the number of Commonwealth observers. I was delighted that the Government were able to increase the numbers significantly. I agree that we should keep the numbers in our mission in Zimbabwe under constant review. It is enormously important that their role in observing what is happening on the ground is maintained. The noble Baroness spoke about how aid might be used in a way not intended by the donors. We shall have to keep that in mind, as I am sure my noble friend Lady Amos would agree.
	The noble Baroness is right. We should try to persuade others not to withdraw their mission. She will know that withdrawing a mission is a potent signal of disapprobation that governments use to indicate the depth of their anger about what has happened within a country. I understand the motivation of our Danish friends in acting as they have. However, my own view is that we should like to see many of our colleagues who value the principles of democracy and humanitarian assistance stay on the ground. That will strengthen those who are able to give honest reports about what is happening in Zimbabwe.

Lord Blaker: My Lords, we should not underestimate the horrors which have occurred in Zimbabwe. However, should we not look ahead on a wider basis to consider how the atmosphere might be changed for the better in the whole of southern Africa? Is not the main and most urgent problem facing all the SADC countries that of economic reconstruction so that they can play their part as a whole in the New Partnership for Africa's Development? As that will require substantial changes in policy, not least in Zimbabwe under whatever government, will it not require outstanding leadership? Is there not an outstanding leader available in southern Africa—I hope that he is available—in the form of Nelson Mandela? Would the Government, with our European allies, consider whether that is a thought which might be pursued?

Baroness Symons of Vernham Dean: My Lords, the noble Lord, Lord Blaker, will know that the NePAD initiative is designed to help southern Africa, both in terms of resources and expertise, to achieve much-needed economic reconstruction. An element of that will be that those who receive such aid and resources should embrace not only the spirit and instruments of democracy but everything that is implied by civil government and the rule of law. In a nutshell, that is what is being negotiated. I am sure that my noble friend will pursue that agenda in her discussions in Monterrey today. Leadership is an important and extremely potent factor in making such an initiative work. A number of individuals in southern African may be able to contribute to that. Given the enormously high esteem in which he is rightly held, not only on the continent of Africa but throughout the world, I am sure that the blessing of Nelson Mandela would prove enormously important to the initiative and its chances of success. However, more than one or two leaders will be needed to ensure that the initiative is a real success.

Lord Thomson of Monifieth: My Lords, as someone who was Commonwealth Secretary during the period of UDI, perhaps I may suggest to the Minister, echoing the words of my noble friend Lord Wallace, that the role of Her Majesty's Government in this difficult relationship with Zimbabwe is best played with a degree of humility about the past. Is the Minister aware how much the success of the troika will be welcomed in deciding to suspend Zimbabwe from the Commonwealth for one year? That will allow other members of the Commonwealth to take a more high-profile role in dealing which such problems, while behind the scenes, and maintaining our own mission there, we play a less prominent role. The Zimbabwe problem is a Commonwealth problem of great importance, but it is one for the Commonwealth as a whole. The more Her Majesty's Government play their role with some delicacy and a low profile, the more successful the outcome may be.

Baroness Symons of Vernham Dean: My Lords, there is an enormous amount of wisdom in the comments of the noble Lord, Lord Thomson. I hope that the Government have been seen to be firm in their resolve. My noble friend and my right honourable friends have done their best to work behind the scenes to secure the objective about which we have been clear. As the Statement indicated, we have been working for suspension from the councils of the Commonwealth for a matter of months. The noble Lord is right. This cannot be seen to be a one-country show.
	As the Statement indicated, it was clear early on in the discussions that the Zimbabwean Government would do everything that they could to make this an issue between the white Commonwealth—those predominantly from the European-based nations—and those from the African-based nations. That would have been an extremely damaging development had it had any success. But it was not successful, which is exactly the point. The value of the troika was that President Obasanjo and President Mbeki both have great wisdom and experience. It will now be extraordinarily difficult for Mr Mugabe to claim that it was some sort of conspiracy led by the United Kingdom. The United Kingdom took no part in the troika. We are also extremely grateful for the part played by Prime Minister Howard.
	It is right to ensure that this is not seen as the United Kingdom being out alone on the issue. We have a special relationship with Zimbabwe. We have a historical relationship and 40,000 of our citizens live in that country. We have particular responsibilities, which none of us want to set on one side. Having said that, we have constantly made it clear that this is a matter for the whole Commonwealth. I am delighted that the Commonwealth has acknowledged that and that it will be working in the next year to try to bring the Government of Zimbabwe to a more sensible course of action.

Lord Stoddart of Swindon: My Lords, the noble Baroness has done well to remind us that there are 40,000 British citizens still living in Zimbabwe. We also know from experience that Mr Mugabe and his party are spiteful. In the event of their taking out their spite on those 40,000 British citizens, are there contingency plans to make sure that they will be rescued and defended?

Baroness Symons of Vernham Dean: My Lords, there is a contingency plan, but I stress to the noble Lord, Lord Stoddart, that there is a similar contingency plan for many other countries. As many of your Lordships will know, we have a warden network around the country to enable us to maintain good communications with the resident British community. I assure your Lordships that that civil contingency plan is reviewed and updated regularly.
	The responsibility for ensuring law and order in Zimbabwe cannot be shouldered by the British mission in Zimbabwe. The responsibility lies full square on the Zimbabwean Government's shoulders. I should not want anything that I have said about civil contingency plans— important though they are—to be thought in any way to be relieving the authorities of that country of their obligation to look after all citizens, irrespective of their nationality or where they live. I hope that that message will be firmly understood.

Lady Saltoun of Abernethy: My Lords, following on from what the noble Baroness, Lady Park of Monmouth, said, how can the Government ensure that any financial support given to restore democracy in Zimbabwe is used for that purpose and does not go towards lining the pockets of the present government?

Baroness Symons of Vernham Dean: My Lords, in countries where we have had the problem of the possibility of governments diverting aid funds from the legitimate purpose for which they were sent and using them for illegitimate purposes we have channelled funds through non-governmental organisations. I am sure that that issue is under review by my colleagues in the Department for International Development. It is another of the functions of our extremely hard-working mission on the ground, and others, to ensure that such matters are kept fully up to date.
	I am sure that none of your Lordships would wish to imply that we should not send much-needed aid for food. As I tried to explain, the levels of hunger and food shortages are enormously difficult problems in Zimbabwe. It is right to send what aid we can to ensure that democracy, fragile as it is, has a chance to flourish and that civil life has a chance to grow as well. We try to do what we can through the NGOs but we also keep very close observance on the ground about what happens to our funds.

National Health Service Reform and Health Care Professions Bill

Lord Hunt of Kings Heath: My Lords, I beg to move that the House do now again resolve itself into Committee on this Bill.
	Moved, That the House do now again resolve itself into Committee.—(Lord Hunt of Kings Heath.)

On Question, Motion agreed to.
	House in Committee accordingly.
	[The DEPUTY CHAIRMAN OF COMMITTEES (Viscount Allenby of Megiddo) in the Chair.]
	Clause 6 [Local Health Boards]:

Lord Roberts of Conwy: moved Amendment No. 76:
	Page 7, line 17, after "is" insert "issued,"

Lord Roberts of Conwy: I shall also speak to the remaining amendments in this group.
	The proposal that there should be local health boards in place of the existing health authorities in Wales is controversial for a number of reasons. Amendment No. 76 proposes that there should be consultation before an order establishing a board is issued by the National Assembly for Wales. There is already provision for consultation in the event of variation or revocation of a local health board order. In our view, prior consultation is essential before boards are established.
	If the boards are to be coterminous with local authorities, there will be more of them than the present five area health authorities. There could be as many as 22—one for each local authority. I should have thought that the Assembly would seek to avoid such proliferation if only for reasons of economy in terms of staff and resources. There will obviously have to be consultation with the existing health authorities, local authorities and health trusts before the final geographical map of health boards is decided. It is important that the map is the best that can be devised and that it is satisfactory to all concerned.
	I can recall the reorganisation of local government in the early 1990s when the present 22 unitary authorities were established. Indeed, I can remember the previous reorganisation in the 1970s. My enduring memory of both is the difficulty that we had in getting proposals accepted and boundaries agreed. These new proposed health boards will prove just as contentious when the Assembly gets down to the business of deciding the precise localities that they are to serve. People are naturally very sensitive about such issues.
	There is a further complication that not all the boards will have the same functions. They will have a variegated pattern of functions and responsibilities. Some will have major hospitals within their areas, and others will not. Again there will be considerable scope for argument and the Assembly would be well advised to consult before the pattern is imposed which, I dare say, will happen.
	Many people in Wales, both within the National Health Service and outside it, have grave doubts about the practicability of the new system. For it to have the smallest chance to succeed, there must be extensive consultation with all the parties involved. We would be foolish not to provide for it in statute, especially when the Bill already provides for consultation in the event of variation or revocation of an LHB order.
	The Minister may say that of course there will be consultation before an LHB order is issued and that we can take that for granted. I do not think that that is an adequate reply to the argument. Without the amendment we shall be storing up trouble for the Assembly and for the National Health Service in Wales.
	Amendment No. 77 is a probing amendment. It seeks to find out how the Assembly proposes to direct the local health boards at national level. In other words, who precisely in the Assembly is to issue directions? Presumably they will be authorised by the Minister in the Assembly on the advice of the NHS directorate. We should like to know more about that top structure.
	I imagine that there will be an infinite variety of directions related to different aspects of the NHS. Some will be purely local and apply only to a particular board or boards; others will be national in scope. As we have said before, the NHS in Wales will clearly need an all-Wales dimension, which is currently not defined in the Bill. It is very important that we have some idea as to what that all-Wales structure will be. We debated this point last Thursday when we considered the new clauses proposed by the noble Baroness, Lady Finlay of Llandaff.
	I had ministerial responsibility for the NHS in Wales between 1979 and 1983. That was a period, I am glad to say, of extensive new hospital building and innovative strategies such as our mental handicap strategy which pioneered the transfer of people with learning difficulties from hospital into the community. We did not have a regional health authority in Wales; the regional authority was the Welsh Office and its Ministers. So I have some idea about the enormous range of NHS activity in Wales even 20 years ago.
	It is quite clear that the thrust of the Welsh provisions in the Bill is to devolve responsibility to local health boards, but it is also clear that there will have to be some central direction in order to ensure a degree of uniformity and fairness all round. It is therefore necessary, as I have said, for us to know what kind of structure the NHS will have at Assembly and ministerial level.
	I referred a few moments ago to the noble Baroness, Lady Finlay of Llandaff, who introduced new clauses asking for a national health agency for Wales. The noble Baroness not only enjoys an international reputation, but she has a high reputation in Wales as vice-dean of the University of Wales College of Medicine and as honorary professor of palliative medicine. In short, she knows the NHS in Wales. She knows the scene very well indeed.
	Last week the noble Baroness told us of the concerns expressed at the conference of Welsh local medical committees as recently as last Wednesday. She said:
	"They cannot take on the huge number of functions about to be devolved to them".—[Official Report, 14/3/02; col. 994.]
	She went on to say that GPs wanted a primary care directorate, but that is now in doubt. What is proposed are six directorates for renewal, policy, finance, quality, human resources and facilities—all six presumably overarched by the existing NHS directorate.
	As the noble Baroness hinted in the debate last week, there is a threat of fragmentation here and, I would add, an incoherent, possibly conflicting guidance to local heath boards from the various directorates. I hope that further consideration will be given to the single primary care directorate and the significant body that the local medical committees want,
	"to handle contractor services to protect both professional interests and those of patients".—[Official Report, 14/3/02; col. 994.]
	With regard to secondary and tertiary care, it is proposed to strengthen the Specialised Health Services Commission for Wales, to commission tertiary care and advise, guide and facilitate the commissioning of secondary care. But the remit is still being worked out, as the noble Baroness told us. The noble Baroness, Lady Farrington, confirmed that the Specialised Health Services Commission for Wales is to be given an enhanced role. But that is as far as we got in learning about the national structure.
	So what can we make of that? The structure of the NHS in Wales is being built from the bottom up. That makes sense, provided that the builders know how the structure is to be completed. The foundations have to match the superstructure, and vice versa. That is where the current problem lies. There seems to be no clear idea as to what the final structure will look like or how it will work. Any help that the Minister can give on this matter will be most welcome.
	Amendments Nos. 90 and 91 are different in character from previous amendments but still deal with local health boards. I have tabled Amendment No. 90 to seek clarification on certain aspects of local health board expenditure. My understanding is that they will have very little income, other than the allocations given to them by the Assembly. Such allocations will be the major part of their revenue. Clause 10(9) defines general Part 2 expenditure under the Act. That means expenditure in connection with the council for the regulation of health care professionals, and appeals. My amendment deletes subsection (2) of Clause 10(9) which excludes four kinds of expenditure that may clearly be incurred by local health boards; otherwise they would not be specified for inclusion in the way that they are. This subsection must be read in conjunction with new Sections 97H and 97G which deal with resource limits of local health boards and their financial duties. Subsection (2) of new Section 97H states that,
	"no account shall be taken of ... general Part 2 expenditure",
	as defined by a board in carrying out its duty not to exceed its expenditure limits.
	My first question is: why is Part 2 expenditure open ended? Is it demand led? It does not say much for the Assembly's sense of priorities that regulatory expenditure is open ended.
	Secondly, why are there the four specific exclusions from the definition? They are a mixed bag. I hope that the Minister will comment on each. I am particularly interested in Clause 10(6)(b), which refers to,
	"remuneration referable to the cost of drugs".
	What does that specific exclusion mean in practice? Does it mean the perpetuation of postcode prescribing in Wales; that certain drugs will be available under one board but not another, depending on whether it has the resources and the will to provide them?
	Finally, who, if not the local health board, will pay for these excluded items? I am bound to say that the whole of the resource and expenditure situation of local health boards is complex, to say the least, in the Bill.
	Amendment No. 91 seeks to introduce the principle of equity into the National Assembly's annual apportionment of remuneration for the cost of drugs. Drugs expenditure is clearly no longer demand led and open ended. There is no commitment here on the part of the Assembly to meet a local health board's drugs bill in its entirety and whatever it may be. Indeed, under Clause 10(9), new paragraph 6C(4) states explicitly that the Assembly will exercise its discretion in paying for drugs ordered by a board on its own account. That seems a shot across the bow for boards that respectfully follow clinical judgment in drug prescribing. The same applies to primary care trusts in England.
	I hope that I have properly understood the financial provisions and that the Minister will be able to answer some of my queries. I beg to move.

Baroness Carnegy of Lour: Those of us who are particularly interested in the workings of devolution are bound to be interested in this part of the Bill, which establishes for the first time an arrangement set up by Westminster in Wales—upon which the National Assembly will make many decisions and within which framework it will operate.
	There are many provisions in the Bill for secondary legislation. The Delegated Powers and Regulatory Reform Committee, of which I am a member, examined that aspect of the Bill with care and on the whole—as the Minister knows—the Committee is satisfied with the way in which the secondary legislation is arranged. It seems to have been well drafted.
	The Bill allows the Assembly enormous freedom to make the arrangements to which my noble friend referred in the way that it wants and which suits Wales. Far be it from me even to imagine the scene, because I have not seen the Assembly in action, but it should be having an interesting time.
	Westminster must decide what should be on the face of the Bill and what should not—and what consultation should be set out by Westminster. Defining the board areas is obviously important. My noble friend made a good point when he said that there must be consultation before orders are made, not just the varying of orders afterwards. Amendment No. 76 probably has a lot going for it. It will be interesting to hear the Minister's response.
	The clause about which I believe many of your Lordships are doubtful emanates from the arrangements for England and Wales—as does much of the pattern of the Welsh clauses. We must be sure that the pattern that is right for England is right for Wales.
	The clauses in question imply that the Assembly will have enormous freedom to spend money on the health service in Wales in the way that it wants. How will the Government fix the Assembly's block grant in relation to health? I do not know whether my noble friend disagrees but that seems so open ended that it might be difficult to do. We need to know whether there is any basis for knowing the overall sum within which the Assembly will have to operate.

Baroness Finlay of Llandaff: I thank the noble Lord, Lord Roberts, for his generous comments about me. I appreciate them enormously and feel humbled by them.
	After last week's debate, I wanted to feel in tune with the views of general practitioners across Wales in relation to the proposed arrangements, so I attended a joint meeting of the Royal College of General Practitioners and the General Practitioners Committee of the British Medical Association in Wales. The turnout was so great that the room booked for the meeting was too small—which reflected a surprising concern among GPs about the changes that they are facing.
	I shall not reiterate the whole meeting, which lasted two and a half hours, but there was resounding concern that the new local health boards would have great difficulty coping with the workload that they are expected to take on and the speed. The new general practitioners' contract, which is currently being negotiated, aims at attracting back into the profession groups who are currently not working—particularly young women—through family-friendly policies, which are to be welcomed.
	There is concern that the different arrangements for local health boards will present them with great difficulties in commissioning secondary care. There is concern in the secondary care sector that some of the arrangements could precipitate a destabilising crisis.
	Concern is felt among patients about the loss of collective memory among those who administer community health services, particularly primary care. They have often provided a safeguard and acted as a point of detection when problems have arisen. I do not want to overplay the problems but one patient said to me at the weekend, "The NHS is working very well in Wales. Why does everybody knock it and need to rearrange it?" The overwhelming experience of patients is that they are getting a much improved service.
	At the meeting that I attended, it was estimated that there would be only two senior administrative managers who really understood the ins and outs of primary care as it has existed. Much work has been done on setting standards across Wales and it will be important to ensure uniform measurement of services against standards.
	Equity is absolutely crucial. It is crucially important that there is no return to the feeling of rationing by postcode. Patients feel that they are being rationed even when they are not and lose confidence in the service. It is not uncommon for patients to ask me whether the failure to offer them a particular form of treatment is because the NHS cannot afford it. When I point out to patients that the treatment was not offered because it would not do them any good—otherwise, they would certainly have been offered it—they often look surprised. Then they comment to the person next to them that they might get extra treatment if they paid for it. There is a perception of rationing even though that may not be true, so it is important that equity is firmly embedded in any new arrangements.

Baroness Farrington of Ribbleton: This has been an important debate and I am particularly grateful to the noble Baroness, Lady Carnegy. Because of her interest in devolution, we spent many hours debating not only the Bill establishing the Assembly but also that which established the Scottish Parliament. No one appreciates more than the noble Baroness that many things have changed.
	As to Amendment No. 76, it is precisely because of the changes in responsibility and accountability that we are not able to accept that amendment. It is for the National Assembly to consider such matters as part of its devolved function. The only practical effect of Amendment No. 76 would be to fetter the devolved powers granted under the Government of Wales Act 1998. I am sure that no one wants to unravel the devolution settlement.
	I hope that I shall give the assurance that the noble Lord, Lord Roberts and the noble Baroness, Lady Finlay, are seeking by saying that the clause has been drafted to reflect the full and open consultation that the Assembly has already undertaken on the establishment of local health boards. In addition to consultation, the secondary legislation necessary to implement local health boards will also pass through the Assembly's scrutiny procedure before it is made, thus allowing Assembly Members an opportunity to comment further on it.
	Imposing a further consultation requirement would seriously delay implementation of local health boards, which are a key feature of the strategy for reform of the NHS in Wales voted for by the Assembly. That would frustrate the intentions of the democratically elected devolved administration which, under the devolution settlement, is responsible for such policy matters.
	Amendment No. 77 is again a matter for the National Assembly to consider as part of its devolved function. Its only practical effect would be to fetter the devolved powers granted under the Government of Wales Act 1998 and prevent the National Assembly from giving directions to local health boards as to how they should exercise any delegated powers—a function that the National Assembly will retain with regard to health authorities. The amendment is therefore prejudicial in relation to England, as the Secretary of State will retain various powers of direction over the equivalent English bodies.
	Directions in relation to the conferring of functions on local health boards must be made in regulations, which will be subject to the secondary legislation scrutiny procedures of the Assembly. They will therefore not be issued directly by the Welsh Minister for Health and Social Services but made by the Assembly under its own processes.
	I turn to Amendments Nos. 90 and 91. Proposed new Section 97F confers a general power on the National Assembly for Wales to determine the treatment of discretionary and non-discretionary expenditure in relation to local health boards. That power currently exists in respect of health authorities, and we intend to transfer it to local health boards. To remove the power would be most unhelpful and unjustified.
	Schedule 12A to the Health Act 1999 provides the mechanism by which the National Assembly for Wales determines the treatment of discretionary and non-discretionary expenditure. It has always been for the National Assembly for Wales to decide on such treatment, subject to the usual constraints, as it is for the Secretary of State in England. Those powers must be exercised in accordance with the principles of administrative law. We therefore cannot agree to limit the powers of the National Assembly for Wales.
	However, some specific reassurances were sought. In answer to the noble Baroness, Lady Finlay, the strengthened Specialised Health Services Commission for Wales will support the local health boards with advice and guidance on commissioning, in addition to its role in commissioning tertiary and other specialised acute services—a point also raised by the noble Lord, Lord Roberts.
	In answer to the question about the post code lottery asked by the noble Lord, Lord Roberts, clearer priorities are emerging through the plan implementation process. Priorities are increasingly delivered through national service frameworks that set clear minimum standards to be applied across Wales. Local health boards will be responsible for assessing the health needs of their populations and securing the range of services to meet those needs. The block vote is given to the Secretary of State for Wales. It is passed to the Assembly after allowing for his expenditure in running the Wales Office. The Assembly then decides how that funding is allocated across its functions. That is decided at a plenary session of the Assembly.
	Local health board budgets will be prescribing budgets. They are currently dispensing at health authority level. Action is in hand to move towards a needs-based allocation. The report debated in plenary session of the Assembly last week determines that direction and was overwhelmingly accepted, I believe.
	Finally, in response to the noble Baroness, Lady Finlay, we intend commissioning partnerships between local health boards, local authorities and NHS trusts to be formed as collective organisations. They will have geographical proximity and common patient flows and we expect there to be between 10 and 12 such partnerships in Wales. A typical partnership could be composed of two local health boards, two local authorities and one NHS trust. Partnerships will not be viewed as organisations but mechanisms for effective commissioning.
	The noble Lord, Lord Roberts, raised the issue of the number and role of local health boards. The boards will be coterminous with local authorities in Wales. Identified benefits include: enabling the development of new and better ways for the NHS to work with local government to implement the health and well-being agenda for Wales; facilitating the requirement for LHBs and local authorities to assess the health and well-being needs of their population; sharing a population focus to provide more flexible services; providing a shared focus to address the determinants of health, which span NHS and local government responsibilities; and providing more flexibility in the use of staff and resources and clear accountability to the local population between statutory bodies.
	The 22 health boards proposed for Wales are a natural development from the 22 local health groups that already exist as sub-committees of the health authorities. Local health boards will pay for admitted Part 2 items. Contracts for primary care contractors will be held by the Assembly, but financial control and scrutiny will be exercised via the local health boards.
	I hope that I have answered in some detail the points raised. I return to the fundamental point, which is that unfortunately the amendments proposed by the noble Lord, Lord Roberts, would undermine the devolution settlement agreed to by your Lordships.

Baroness Carnegy of Lour: Before the noble Baroness sit down, in relation to Amendment No. 76, she said a good deal about how times have changed and that the matter is up to the Assembly. We know that, but we must consider what Westminster has to do by way of constructing a framework within which the Assembly will work. Proposed new subsection (4) states:
	"If any consultation requirements apply, they must be complied with before an LHB order is varied or revoked",
	Why should that not apply when an order is issued, as my noble friend Lord Roberts suggested? The Minister made a somewhat specious argument.

Baroness Farrington of Ribbleton: I am sorry if the noble Baroness feels that the argument is specious. These matters are rightly for the Assembly to determine. Unlike that which established the Scottish Parliament, the settlement gives the National Assembly for Wales the power to develop its own instruments and orders in secondary legislation.
	The noble Lord, Lord Roberts of Conwy, presses us to accept that, as it were, a member of our family has reached the age of majority, but that we should still control the way in which he exercises his adult rights. The primary contractor contracts will be held by LHBs. I hope that that is an additional piece of information for the noble Baroness, Lady Finlay.
	I assure the noble Baroness, Lady Carnegy of Lour, that we are being extremely careful to ensure that during the passage of this legislation Members are kept informed about the degree to which consultation forms the ethos of the exercise of the Assembly's devolved powers.

Lord Roberts of Conwy: We are all grateful to the Minister for her comments. I am grateful to my noble friend Lady Carnegy of Lour and to the noble Baroness, Lady Finlay of Llandaff, for illuminating us on the feelings of GPs, particularly in Wales. I listened to her with great care. She talked about their concern, not only on this occasion but also last Thursday, as a result of their meetings. I know that such concerns about the formation of these boards are real in Wales.
	It is all very well for the Minister to say that the Assembly must consult if an order is varied or revoked, because that is required here in primary legislation. But the Assembly does not have to consult when an order is issued, which is what the amendment seeks. There is a contradiction in the Minister's approach, which states that we ordain in primary legislation that when a local health board is varied or revoked, the order must be consulted on, but that there is no need for consultation before the first order is issued. The Minister says that consultation has taken place. I am sure that there has been endless talk within the NHS in Wales, but there is still a considerable degree of dissatisfaction among professionals there.
	My experience of local health reorganisation and also local government reorganisation in Wales on more than one occasion is that public consultation is essential, otherwise discontent prevails and the system fails to work.

Baroness Farrington of Ribbleton: It may help the noble Lord, Lord Roberts of Conwy, to recall, as I believe he knows, that I was involved as the leader of the Association of County Councils during the period of local government reorganisation in Wales. I was assured by the noble Lord's government when in office that everyone had been fully consulted. I fear that occasionally, irrespective of who carries out the consultation process, some of those consulted will never accept that it took place unless they obtain the results that they want. Sometimes there are conflicting demands and it becomes impossible for everyone's views to be met.

Lord Roberts of Conwy: I accept that one cannot please everybody; one cannot please all the people all of the time, but we hope to please some people some of the time. That does not dispel the need for consultation. In such an area, where we are establishing totally new local health boards—22 in place of the existing five—there is a duty on the Assembly to ensure that the orders establishing the boards have been well and truly consulted on.
	If there is no such consultation and ensuing satisfaction, the worst fears expressed within the NHS in Wales—that the system is impracticable—may be realised. We are not fettering the Assembly in any way as it is already obliged to consult if the order establishing an LHB is varied or revoked, as I pointed out. We will not fetter it additionally by inserting the word "issued". Perhaps the principle should have been established earlier, in new subsection (2), but it is here. It fits into that subsection.
	We are still unclear about the top end of the NHS in Wales and how it will be constructed. We know a great deal about the lower end of the spectrum—the local health boards, and so on—but little about what is meant by the Assembly and the Minister and the form of organisation within the Assembly. I am not altogether happy with the Minister's answer and I shall test the Committee's opinion.

On Question, Whether the said amendment (No. 76) shall be agreed to?
	Their Lordships divided: Contents, 86; Not-Contents, 109.

Resolved in the negative, and amendment disagreed to accordingly.
	Clause 6 agreed to.
	Schedules 4 and 5 agreed to.

Lord Filkin: I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.
	House resumed.

Hunting with Dogs

Lord Whitty: My Lords, with the leave of the House, I shall now repeat a Statement made by my right honourable friend the Minister of State for Rural Affairs in another place. The Statement is as follows:
	"Mr Speaker, our manifesto gave a commitment on hunting with hounds. We said:
	'We will give the new House of Commons an early opportunity to express its view. We will then enable Parliament to reach a conclusion on this issue'.
	"I have been given the responsibility of leading that enabling process.
	"In reaching my decision on how to proceed, I have listened carefully to what has been said in the debates.
	"The votes this week leave the two Houses diametrically opposed. Indeed I have rarely seen an issue where greater divisions exist. It is precisely for that reason that it is right to see how it can be resolved with as much agreement as possible.
	"We want to respect all views but that has to start with respect for the strength with which the Commons made its views clear on Monday.
	"I promise to engage with everyone who has an interest in this issue in order to make the legislation practical and robust. I promise to bring to the House of Commons a Bill that will deal with this issue effectively once and for all and make good law; and I earnestly hope that we can do so on the basis of as much common ground as possible.
	"I propose a process of consultation on the practical issues of detail with a wide variety of interested parties. This period will last no more than six months, including work on drafting a new Bill.
	"But we promised in the manifesto that it will be resolved. Should there be no way through and should the new Bill be frustrated in its passage rather than scrutinised and improved, the Government could not properly stand in the way of the application of the Parliament Act, which again of course would be a matter for this House.
	"So the Government would prefer for the Bill to proceed by debate and a search for common ground wherever possible, with conflict tempered by tolerance. If that process is frustrated and the Bill rejected, we would reintroduce the Bill as quickly as possible to this House. It will then be for this House and its procedures—and indeed for Mr Speaker—to determine whether the Parliament Act applies.
	"However, the reason for re-engaging in a process to try to achieve wider agreement is precisely because we recognise that there are legitimate concerns in the countryside about pest control, about land management and about other practicalities and we want to address these issues in the Bill. These concerns were raised both in this House and in another place.
	"Let me also reiterate our manifesto commitment that:
	'We have no intention whatsoever of placing restrictions on the sports of angling and shooting'.
	"And I also want to stress to everyone in the countryside that hunting is at the margins of the real debate about the priorities that we set out in the Rural White Paper. Those of ensuring that people in the countryside get access to good public services, proper investment, sound environmental policies and sustainable development.
	"On the content of the Bill itself, I believe that some common ground can be achieved best by focusing on two general principles. The report by Lord Burns on hunting with dogs examined in great detail the principles of cruelty and utility. We propose to frame legislation that prohibits activity based on those two principles rather than simply setting out a list of activities to be banned.
	"But the Burns report did not provide a route map. That is why further thought needs to be given in applying these principles and that is what I shall be looking at over the next few weeks.
	"I am sure the House will have noted the very clear assurances I have given today about timing and outcome, as well as engagement which will involve those campaigning for a ban on hunting, and Members of this House, as well as those involved in land management.
	"Inevitably, I recognise that this is a difficult issue, especially as we all know that there are pressing issues of legislation that also demand our attention on crime, health and education. We must deliver on our central promises to deliver reform and investment in our public services.
	"Mr Speaker, I ask the House to trust me to deliver and to join me in a process which is guaranteed to achieve an outcome as soon as possible. I look forward to engaging with colleagues on all sides of this House and in another place.
	"The process I am setting out today will ensure that we deliver on our manifesto commitment to resolve this issue during the lifetime of this Parliament".
	My Lords, that concludes the Statement.

Baroness Byford: My Lords, I thank the Minister for repeating the Statement made in another place earlier today.
	We congratulate the Government on recognising the need to make good law and on their determination not to place restrictions on angling and shooting. I recommend the Government wholeheartedly on this point of good law because it is at the heart of the issue. As many of your Lordships commented during our debate, it would be wrong to distract our police forces, to whom I pay tribute for the job of stemming the rising tide of crime. This is one aspect of a wider issue. The Government's continuing determination to give a ban on hunting the highest priority when so much else is clamouring for attention is a disgrace.
	The Statement requests this House to trust the Minister to deliver. Does this mean that the Prime Minister has given him carte blanche to achieve a solution? Although the Statement declares that the two Houses are diametrically opposed, will the Minister accept that on a free vote in this House and in another place earlier this week the two Houses declared themselves to be in favour of a middle way?
	We do not accept that this is a black and white issue. It is a wide continuum, with many people sitting in the middle; and that fact tends to go overlooked. Is the Minister not willing to concede that the Statement he has given us today, while seeking views, also carries an uncanny unveiled threat that the Government will use the Parliament Act, and that even prior to us knowing what is going to be in the consultation document?
	I turn now to the consultation period. Are these consultation papers ready? If not, how long will it be before they are issued? Mindful of Easter and the Jubilee celebrations coming, will there be time for the Minister to fulfil his promise to engage with everyone who has an interest in this issue?
	Earlier this afternoon in another place the Minister seemed to suggest that the noble Lord, Lord Burns, had had his shout and that further interpretations by him of his report would not be considered. Are we to understand that the new round of consultation that is proposed will involve only those interests which have not already been expressed? Are we also to understand that the noble Lord, Lord Burns, will have no further input into the definition of "cruelty" and of the other word used in the Statement, "utility". Can the Minister explain to the House a little more about what is meant by "utility"?
	I point out to the Minister that while the rural White Paper might be highly valued by the Government, as indeed they keep telling us, it was produced back in November 2000. It has not even been debated in this House and its implementation seems to be entrusted to many of the regional development agencies. Those have only one rural member on each board. Is it any wonder that the Government have had to use the Statement to point out to us and to the wider world that hunting is not a central issue in the countryside?
	While the Minister is pressing the issues for legislation referred to in the Statement we are still awaiting the Government's response to the Curry report and indeed to the reports that have been produced by the noble Lord, Lord Haskins, who I do not think is in his place today, on better regulation and on the response to the FMD prices in Cumbria. These are just a few. There are many other reports waiting in the wings.
	Finally, I ask the Minister where the newspapers obtained their most authoritative articles published today in advance of the Statement, which rather suggests insider knowledge. Were there any briefings and did they take place before the Minister rose to speak in another place?

Baroness Miller of Chilthorne Domer: My Lords, I would not pretend to speak for all voices in my party because in my party too we have diametrically opposed views. However, following the Statement, which I am glad the Minister has been able to make this afternoon, we can be certain of one thing, which is that we are not entirely clear what it means.
	Having said that, I welcome the fact that it makes clear that the Burns inquiry is to be taken seriously. I welcome also the fact that the Government, having commissioned an inquiry, are going to take notice of it. I would certainly interpret the cruelty and utility part as exploring the balance between pest control and sport. That is a very important balance which should be thoroughly explored.
	I, too, should like to know more about the timescale for the consultation and also whether local views will be taken into account on a locality basis or a regional basis; and, if so, what bodies will be consulted locally. That is particularly important because of the practical issues—if the Government are thinking of restricting hunting to certain areas, for example, uplands. The over-use of those upland areas is a matter which bodies concerned with them will no doubt want to consider as well. It would be reassuring if the Minister could, at some stage, give us an indication of how the consultation document will dovetail into the recommendations made in the food and farming report. Indeed, as the noble Baroness, Lady Byford, observed, we have not yet received any response to that report.
	The economic and social aspects would be well addressed on a regional basis. There are also issues of compensation for those who will be put out of business, as was mentioned during the passage of the fur farming legislation in this House; and, indeed, as regards housing. I believe that the time-scale involved is most important. It means that we shall finally have definite answers. That is as crucial for rural areas that will be affected, as it is for those who would like to see a ban imposed.
	Further, it is important to ensure that the sort of turn-out that we saw in this House last Tuesday will be repeated and exercised on other issues in the future. One way or another, it would be pleasant if the hunting debate could be put to bed once and for all in a satisfactory manner.

Lord Whitty: My Lords, I appreciate the response to the Statement and the questions that have been raised. I believe that some of those questions seemed to suggest that the way we do these things is slightly misleading. The noble Baroness, Lady Byford, seemed to think that I have been empowered by the Prime Minister to carry through the process. However, I am the mere representative in this House of my right honourable friend Alun Michael who—thank goodness!—is the person who will have that responsibility. Nevertheless, I shall be responsible for processing the matter through this House.
	In his Statement, my right honourable friend made it clear that he would wish to engage with Members of this House, those who expressed views in the debate in another place on Monday, and, more widely, with the interest groups involved. It is not a question of the views already expressed being taken as written, including those of the noble Lord, Lord Burns. We shall facilitate the process so that anyone else who wishes to do so may participate in the consultation. I cannot give an answer on precisely when the consultation documentation will be produced, but, following the Easter Recess, we shall start engaging in the process of consultation.
	In response to the noble Baroness, Lady Miller, I should point out that this matter needs to be very much separated from other consultations that will take place in terms of how we proceed with the Curry report, to which the noble Baroness, Lady Byford, also referred. The initial response to that report will be available shortly. However, as I have already indicated to the House, we wish to engage in a programme of regional discussion over the spring and summer. The final response to the report will be produced in the autumn, by which time we shall have the advantage—if I may put it that way—of finalising the spending review and other decisions of government. We are, therefore, aiming to produce a White Paper in the autumn.
	The noble Baroness, Lady Byford, made a few aspersions in relation to some reports in today's newspapers. I can assure the noble Baroness that there was no such briefing; indeed, when I left my department at 1 o'clock this lunch-time, the Statement had not been finalised. Therefore, it would be impossible for anyone to have received it before that time. I believe that we can ignore that aspect of the matter.
	However, the more important accusation that the noble Baroness made related to fact that, by this Statement, we are threatening further action. Everyone has known the potential constitutional position both on the previous, and on any new, legislation. The noble Baroness introduced the rather novel constitutional precept that I have heard repeated quite widely around the House over the past 48 hours; namely, that we would add up the scores of this House and those of another place. As noble Lords well know, that is not the way that the procedure works. Both Houses have to reach their conclusion, and it is to be hoped that we reach a conclusion that is at least acceptable, even if it is not entirely what either wants. However, if that process fails, the Government—or, more accurately, the House of Commons, as it will be on a free vote—would have the option of invoking the Parliament Act.
	We believe that this issue has been around for long enough. We have had a sufficient number of debates on the subject, in which everyone has expressed his or her point of view. If, following the consultation—and, it is to be hoped, the taking on board of many of the points raised—the Bill then produced is adopted by the House of Commons, we are indicating that we would not stand in the way of the other place using the Parliament Act finally to resolve the issue, and thus meet our manifesto commitment that we would solve the matter in this Parliament.
	Mention was made of the definition of "utility". Clearly, the prime reason for hunting tends to be pest control. However, there are other potential benefits from hunting, including economic considerations, that will need to be taken into the balance. The main concern among those who wish to promote a restriction or a ban on hunting is, of course, cruelty. When the noble Lord, Lord Burns, referred to "cruelty", I believe that he did so in the context that we already have a definition in existing legislation. The issue is whether the consideration of other factors means that the definition of the word has at least to be modified in the light of aspects of utility. We are not balancing one against the other, but we must also take issues of utility into account. That is the basis of the approach to drafting the new Bill.
	The response to the Statement indicates that we still have a long way to go in the consultation process, in the re-engagement of the various parties—both parliamentary and otherwise—and in the drafting of the Bill. We have given an indication of the time-scale on which the Bill will be produced—namely, six months—and of the process that will ensue if, regrettably, we still end up in a deadlock. That is simply a statement as to the reality of the situation. I hope that we can move to more of a consensus on the issue. However, if we cannot, the use of the Parliament Act is, therefore, promised.

Lord Hurd of Westwell: My Lords, it seems to me that the Minister has not fully understood the point made by my noble friend on the Front Bench about the leak of information. She was not suggesting that the contents of the Statement had been leaked: I believe that my noble friend was referring to the very detailed accounts to be found in several newspapers this morning. Such reports referred not to the Statement but to the Bill that will eventually be introduced. Is that not rather a serious matter?
	When repeating the Statement, the noble Lord talked about certain principles and a process of consultation after which time a Bill will be produced. However, it is quite evident that someone connected with government has been reassuring those in favour of a total ban that their wishes—90 per cent according to one report—will be met. That reflects quite a different, divisive and belligerent approach, and, indeed, one quite contrary to what the Minister has been trying to convey to the House this afternoon. Can he clarify the position?

Lord Whitty: My Lords, I can assure the House that no Bill exists; nor does even the outline of such a Bill exist. However, all of these issues have been fairly well aired, and, in the light of the contrary decisions of the two Houses, they have been discussed widely in political and journalistic circles. I assure the House that there has been no decision on the nature of the Bill pending the consultation, and there has been no spelling out to journalists or anybody else what the nature of that Bill will be. My Statement today clearly indicated the process. Also, it is stating the obvious to say that we know where the House of Commons stands and we know what will be required to meet many of the present concerns in the House of Commons. We have a consultation period to undergo, during which we can perhaps establish more common ground on which a further Bill could be based. In any case, the position taken by the other place the other night would need to be translated into legislative terms and there are different ways of doing that.
	So, in relation to belligerence, I am afraid that I have to make it clear to Members of this House that, at the end of the day, their votes cannot be added to those of the House of Commons and, if the normal process fails, the will of the House of Commons will prevail.

Lord Hoyle: My Lords, I welcome the early response from the Government. I also welcome the fact that, if a real debate does not take place, the Parliament Act will be used and the fact that due weight will be given to the views of the elected House. I hope that the spirit of libertarianism that was shown in the House the other day continues for a long time.

Lord Whitty: My Lords, I accept the welcome from my noble friend. There will be different interpretations of precisely what he meant by his last sentence. No doubt, he will enlighten us.

Lord King of Bridgwater: My Lords, the Minister rightly said that it could not be guaranteed that the votes of this House would be counted equal to those of the House of Commons. However, he gave the House a pledge on behalf of his colleague, Mr Alun Michael—who, as he said, is in charge of the matter—that the views expressed in this House would be carefully considered before any decisions were taken. I am sure that the Minister gave that pledge in good faith, but it has been dishonoured by the Statement.
	There is no secret about it. Anyone who has been around for any time in government or Parliament knows what the Statement means. The views of the House have not been taken into account, and that is the worst possible prelude. The Minister pleads for understanding, co-operation and proper consultation, when the first process of consultation—a proper debate in this House and a proper moment for the assessment of our views—has been so manifestly dishonoured.
	The Statement was fairly opaque in places. On the second page, there are clear assurances about timing and outcome and that there will be engagement with those campaigning for a ban on hunting, Members of the House of Commons, Members of this House, and those involved in land management. There is no indication that there will be any engagement with those who happen to regard the policy—if the newspaper reports of it are accurate—as a disaster for many parts of the country. They would expect to be fully engaged in the process.

Lord Whitty: My Lords, my right honourable friend made it clear that he would engage with all sides of the argument. The Statement refers to Members of the House of Commons and the view that they took. It was, after all, a Statement to the House of Commons, which has made its views clear, and the Minister is responsible to that House. It also said explicitly in the Statement that he would take into account views that had already been expressed here in the debate and views that might be expressed during the six-month period.
	The Statement is not opaque. At least, it is no more opaque than many government Statements. It is fairly clear that the process of consultation will take place; that there will be an assessment of the views that are put to Alun Michael during that period; and that the Bill will be drafted in the light of those opinions. It is a political reality that the House of Commons has made its view clear, as of now. It is also clear that there will now be a period of reflection and consultation, before we produce the legislation. When we produce the legislation, it will go through the normal process. I hope that we can establish other principles and bases for that legislation. The only thing that is spelt out—it is blindingly obvious, not opaque—is that, at the end of the day, we think that the issue has gone on for too long and the Parliament Act might be invoked.

Lord Greaves: My Lords, I shall take up the point made by—I was going to say, "my old friend", but that is not appropriate in this House—my old sparring partner, the noble Lord, Lord Hoyle. Up to now, this has been a matter for a free vote, here and in another place. That was true of the previous Bill, in which there were three options. People were able to vote for what they wanted. It has also been true of the debates in this Parliament.
	Are the Government saying that they will introduce a government Bill that will represent their settled view, after the six months' consultation, and that they will do what they usually do with government Bills and apply the Whip, in this House and in another place? If that is not the case, what guarantee is there that the Bill that arrives in this House from another place will be the Government's Bill?

Lord Whitty: My Lords, contrary to what the noble Lord, Lord Greaves, suggests, we have made it explicit that, although the Government will produce the Bill, it will be the subject of a free vote in both Houses, as was the Private Member's Bill and as were the Motions debated this week. The principle of a free vote throughout Parliament still applies: Whips will not be applied on this side of the House or, I suspect, in other parties.
	I hope that that clarifies the situation. Of course, the Bill that arrives here will be the House of Commons' Bill, which may not be the same as the original government Bill. That is stating the obvious.

Lord Donoughue: My Lords, I congratulate my noble friend on the Minister's decision to have a period of reflection, rather than follow the line of a "virtual ban", which was apparently briefed overnight from somewhere to the newspapers. That is a positive move.
	Following up what was said on the Benches opposite, I ask the Minister for a positive assurance that the final Bill, which will include the Government's decisions, will, in the search for common ground—a crucial part of the process and a good objective—include not only the views of this House as part of Parliament but those of the people in the countryside who will be most affected by a virtual ban, should the Government pursue that policy.

Lord Whitty: My Lords, I cannot predict the extent of support for the common ground that will emerge from the process. All I am saying is that it will be the objective of my right honourable friend to seek what common ground there is, before producing a Bill.

Lord Elton: My Lords, the Government have accepted the principle that foxes must be controlled and seek to implement the principle that unnecessary cruelty should not be inflicted, with which one cannot quarrel. Can the Minister give an undertaking that no law will be passed that substitutes a more cruel or equally cruel method of control than fox hunting?
	The Government said that they,
	"could not properly stand in the way of the application of the Parliament Act",
	if the new Bill were to be frustrated in its passage, rather than—I emphasise—"scrutinised and improved". Will the Minister undertake that, if the role of this House is restricted to scrutiny and improvement, the Government will properly stand in the way of the application of the Parliament Act?

Lord Whitty: My Lords, as I said, the Bill will go through the normal process. If improvements are introduced in this House during that process and they are acceptable to the House of Commons, they will be accepted in the Bill. However, were there still to be deadlock, the situation that I described in relation to the Parliament Act would apply. If the question is whether it is worth while for this House to scrutinise and attempt to improve the Bill, the answer is that it is. That is part of the process of trying to reach as much common ground as we can through parliamentary and other processes.
	I am not sure that I can give the noble Lord, Lord Elton, a straight answer to his first question. After all, as my noble friend Lord Hoyle and others said, only about six per cent of the control of foxes is through hunting with hounds. There are subjective arguments about whether that is more or less cruel than other forms of controlling foxes. The question is whether that six per cent should continue to exist, be reduced or eliminated. The balance may well depend on the exact outcome and the exact law. I cannot give a clear assurance on that either way.

Lord Campbell-Savours: My Lords, my noble friend will be aware that some of us who are opposed to hunting are nevertheless concerned about the impact of a ban on the foot and fell packs in some of Britain's national parks. I refer in particular to the Lake District National Park where special conditions exist, most especially in the area of lambing. Can my noble friend give an assurance that during the course of the consultation, adequate regard will be given to those difficulties?

Lord Whitty: My Lords, local concerns will be taken fully into account during the consultation. I should have made that point clear in my response to the noble Baroness, Lady Miller, because she too asked whether local concerns would be taken into account. Although we may not put in place an entire structure of local consultation, we shall need to take into consideration the conditions and problems peculiar to certain parts of the country, including the Lake District.

Baroness O'Cathain: My Lords, are the consultation documents ready for publication? If not, when will they be ready? Once they have been prepared, when will they be circulated?

Lord Whitty: My Lords, I regret that I cannot give the noble Baroness answers to her questions. The documents are not ready; they are not even at an early stage of drafting. However, following the Easter break we shall be very much engaged in the process and documentation will form a part of that. Although the documents do not exist at present, they will do so very shortly. More than that, I cannot say.

Lord Monson: My Lords, in the Statement the Minister proclaimed that hunting is on the margins of the real debate about the priorities set out in the rural White Paper. While that may be true or partly true, will he accept that hunting is not by any means on the margins of the real debate about the growing threat to British traditions of individual freedom?

Lord Whitty: My Lords, I do not accept that. Hunting is an issue which can cause great excitement on all sides of the argument and therefore its importance is exaggerated by those both for and against it. That is the case in all kinds of contexts, including those of human rights. I do not believe that whether or not we ban hunting has any serious implication for other aspects of life, whether rural or in our more general civic society. Views on hunting are minority opinions on both sides of the argument, although both sides believe that it is extremely important.

Baroness Golding: My Lords, can my noble friend say when the period of six months' consultation is to start? It was made clear in the other place that it was due to start now. However, if the consultation papers have not yet been sent out, or if they have not even been prepared, then when will the six-month period begin?
	Can my noble friend also tell the House who, once the submissions have been made, is to consider them?

Lord Whitty: My Lords, the six-month period does indeed start now.

Noble Lords: Oh!

Lord Whitty: My Lords, there is no inhibition on Members of your Lordships' House or on anyone outside this place with regard to expressing their views before they have received a particular document. This issue has been around for so long that it is not necessary to consult a document in order to express views.

Baroness Byford: My Lords, I think that the noble Lord has been a little disingenuous to the House.

Baroness Farrington of Ribbleton: My Lords, order. This is the time allotted to Back Benchers for questions.

Baroness Carnegy of Lour: My Lords, it seems that the root problem for the other place is the fact that people enjoy hunting with hounds. Can the noble Lord assure the House that, should the three million anglers who go fishing begin to show the slightest sign of enjoyment, they too will be in trouble?

Lord Whitty: My Lords, I share with the noble Baroness her incredulity that any enjoyment can be derived from angling. Nevertheless, we have made it absolutely clear that no such intention will be pursued in relation to shooting or angling.

Baroness Golding: My Lords, the Minister did not respond to my second question. Who will consider and prepare the legislation?

Lord Whitty: My Lords, it is intended that the Government will consider the matter and produce the Bill. It will then go through the process that I have already described.

Lord Monro of Langholm: My Lords, the Minister said that there will be no restriction on shooting, but day after day restrictions are being imposed by stealth. It is becoming harder than ever to acquire a shotgun certificate, in particular for young applicants. Ultimately shooting will be dramatically affected by such practices.
	Can the Minister give me an assurance that he will speak to the government business managers of another place and say that we do not expect another place to guillotine the Committee stage, guillotine the proceedings on Report, guillotine the Third Reading and then send on to this House an absolute shambles of a Bill? We want to hold a proper, democratic debate so that each side is given a fair amount of time. In that way we shall be able to make progress in this House. However, that will not be achieved under the authoritarian attitude with which legislation is presently dealt with in another place.

Lord Whitty: My Lords, I would not dream of trying to instruct the business managers of another place. That has long been the tradition of this House. If the converse were the case, this House would rightly resent it.

Lord Palmer: My Lords, could the noble Lord explain once more to the House why hunting with dogs should take precedence over all the other desperately pressing problems facing the country? Many people do not understand why hunting is so much more important.

Lord Whitty: My Lords, I appreciate that many Members of your Lordships' House find it difficult to understand this matter. Nonetheless, hunting has been a major political issue for over two decades in this country. It is time that it was resolved. In our manifesto, for which people voted rather overwhelmingly, we gave a commitment that the question would be resolved during this Parliament. We are therefore fulfilling our promise.

Lord McNally: My Lords, does the Minister agree that the request for trust put forward on the part of his colleagues has been made on rather shaky ground, given that both sides of the argument can claim to have been badly misled by the Government in their handling of this issue over the past four years? Does he further agree therefore that the period of consultation needs to be transparently fair, thus ensuring that no complaint can be made by either side about its ability to have its opinion heard, and so that there is no temptation to indulge in extra-parliamentary action? It is very important that Parliament should handle this issue—on which great emotions are felt on both sides—so that both opinions are assured that here, in Parliament, they have had a chance to state their case.
	When I spoke in the debate the other day, I put forward a proposal to set up a pre-legislative Joint Select Committee. Whether that was effective, I do not know. However, some means must be found to ensure that the campaigning groups outside this place are given access in the most transparent manner before legislation is brought forward. At the moment, the Government's record on this is very shaky indeed.

Lord Whitty: My Lords, I do not accept the first or the last points put by the noble Lord. We have genuinely endeavoured to find a solution. I can assure him that the consultation process will certainly be transparent. It will be accessible to all the groups to which he referred, as it will be to all parliamentary opinion.

Lord Denham: My Lords—

Lord Williams of Mostyn: My Lords, we have had 20 minutes of questions on the Statement from Back Benchers, but I feel that the House would like to hear from the noble Lord, Lord Denham, if he can keep his remarks fairly brief.

Lord Denham: My Lord, I am most grateful to the noble and learned Lord the Leader of the House. On a point of order, the noble Baroness stated that 20 minutes are allotted to Back Benchers. The first proceedings on a debate of this kind are taken by the Leaders of all sides, and responses are given to them. It is then the turn of Back Benchers for the following 20 minutes.
	I should like to ask for clarification. I have never understood that it would be out of order, if a point arose during the time allotted to Back Benchers, for someone on the Front Bench who had spoken previously to rise to query a minor point? I had not realised that he or she would be out of order in so doing. Is that right or is that wrong? I should not like to make a point of order "on the hoof", so to speak. Perhaps we should consider whether or not this is wrong.

Lord Williams of Mostyn: My Lords, the basic answer to the question put by the noble Lord, Lord Denham, is to be found in paragraph 4.81 of the Companion:
	"The period of questions and answers which then follows for backbench Members should not exceed 20 minutes from the end of the minister's initial reply to the Opposition spokesmen".
	That is the principle. I do not think that it deals particularly with the noble Lord's question because I do not believe that specific guidance can be found. What I try to do is to meet the wishes of the House as appropriate.

National Health Service Reform and Health Care Professions Bill

House again in Committee.
	Clause 9 [Funding of Local Health Boards]:
	[Amendments Nos. 78 to 83 not moved.]
	Clause 9 agreed to.
	Clause 22 [Health and well-being strategies in Wales]:

Lord Roberts of Conwy: moved Amendment No. 84:
	Page 28, line 30, at end insert ", and indicate which authority is to take the lead in the formulation of such strategies"

Lord Roberts of Conwy: Amendment No. 84 relates to Clause 22 and deals with health and well-being strategies. The concept of such strategies drawn up by local authorities and local health boards is attractive. We are all aware of the relationship between people's health and their physical and mental environment, and of the inevitable overlap between the health sphere and the sphere of local government.
	There are some areas—I am thinking particularly of social services—where there is a close relationship which is to be found in all parts of Wales. The relationship may be particularly important where there is a high proportion of elderly people in the population, as in the retirement areas of North Wales. There are other areas, such as the valleys of South Wales, where the working environment and its legacy may still be an important determinant of people's health. I am sure that there are other areas where housing conditions are a primary concern. We still have a great deal of pre-1918 housing.
	Health and well-being strategies are therefore likely to vary in their priorities in different parts of Wales. Obviously, they will also have much in common, such as health promotion, but my main concern is to establish through the amendment which body is to take the lead in drawing up such strategies.
	The clause opens by laying a duty on both types of authority—local government and health authority—to act jointly in formulating and implementing strategies. But, as I am sure the noble Baroness will realise, the danger is that neither will get far without one or other taking the lead, depending on what is perceived to be the major problem of the area and whether it is clearly in the health field or a local government responsibility. The clause is silent on that point. I shall be interested to hear what the noble Baroness has to say. I beg to move.

Baroness Farrington of Ribbleton: The noble Lord, Lord Roberts of Conwy, has raised an important aspect of the Bill in terms of the way in which the formulation of policies will occur within the local health boards. The effect of the amendment would undermine the principle of joint ownership of each health and well-being strategy and the partnership principles which underpin the NHS Plan in Wales.
	The National Assembly will give advice in guidance about how the responsible bodies should work jointly to formulate and implement the strategy. In doing so, the National Assembly intends to leave as much as possible to local determination. Local partners, therefore, will determine the local arrangements.
	It is the wish of those involved in developing the proposals in Wales that these partnerships will be across local government and the voluntary sector and, as the noble Lord recognised, develop in line with the circumstances prevailing in particular health board areas.
	However, I am able to reassure the noble Lord, Lord Roberts of Conwy, that should any problem arise where a particular health and well-being strategy was not being progressed under the joint requirements, the National Assembly would seek to work with the relevant authorities to find a solution. It could ultimately use direction-making powers were they to be necessary. In the light of those assurances, I hope that the noble Lord will not press his amendment.

Baroness Carnegy of Lour: Before the noble Baroness sits down, perhaps she will try to imagine the situation that will arise when this part of the Bill is implemented. I am sure that she is well placed to do so. Would it not be helpful to the Assembly if it was required to decide who was the lead authority? There could be a problem in this area, and all that my noble friend is suggesting is that the Assembly should be required to do that—naturally in consultation. To leave it out would be asking for trouble for the Assembly.

Baroness Farrington of Ribbleton: I have failed to make clear the position which is being taken by the Assembly following detailed consultation. It is taking the view that it is not for the Assembly to direct who the lead authority should be but that that should develop at local level. The local partnership should bring in all parties to consider how best to develop the health and well-being strategy. The view that one authority must be the lead authority imposed by the Assembly is in conflict with the whole ethos of the development of the health service strategy in Wales.

Lord Roberts of Conwy: I am grateful to the Minister for her reply. I made the point simply to highlight the possibility that there could be difficulties so far as leadership was concerned in formulating these health and well-being strategies. She has reassured me. Indeed, I am reassured by the contents of the Bill because Clause 22(6)(b) refers to the fact that,
	"The regulations may, in particular, make provision as to ... steps which the responsible bodies must take before formulating the strategy".
	I heard what the noble Baroness said about the fact that if there is difficulty the Assembly can step in, but it is quite clear—I do not think that she will dissent from what I said earlier—that the primary concerns of these strategies will vary as between different areas. It is important that that point is taken on board and that the Assembly, if necessary, can give guidance as to who should take the lead. Having been reassured by the noble Baroness, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Clement-Jones: moved Amendment No. 85:
	Page 28, line 46, at end insert—
	"( ) the imposition of a duty on the responsible bodies to include steps to improve the eye health of, and the provision of eye care to, the public in the area."

Lord Clement-Jones: In moving Amendment No. 85, I shall speak also to Amendments Nos. 87 and 159. The Minister will note that this is my one foray into Welsh health matters. I do so only because of the importance of the issue of visual impairment. The amendments cover both England and Wales in different ways.
	Clause 22 imposes a duty on local authorities and local health boards in Wales to formulate and implement a health and well-being strategy for their area. Amendment No. 85 would help to ensure that regulations made by the National Assembly for Wales could include provision for a duty to be imposed on both to include steps to improve the eye health of, and the provision of eye care to, the public in each area.
	Amendment No. 87 is designed to ensure that any health improvement plan drawn up under the Health Act—I apologise if I have confused the Minister. There is a misprint in the amendment. The reference should be to the Health Act 1999, not the Health and Social Care Act 2001. The Bill should include a strategy,
	"to improve the eye health of, and the provision of eye care to, the public in the area",
	and, of course, that applies to England. These two amendments are promoted by the Improving Lives Coalition, which is composed of over 100 organisations in the field of visual impairment.
	Why are the amendments necessary? Eye health is accorded low priority at primary care level and has not been a major feature of health improvement plans. Despite the prevalence figures, eye health has been accorded woefully little importance by primary care planners.
	One of the reasons for this is that there is a mistaken assumption that visual impairment is a low incidence disability. That is not correct. Two million people in the UK are affected by uncorrectable sight loss; two-thirds of these have another disability or a serious health problem such as deafness, arthritis or diabetes. Currently, 90 per cent of blind or partially sighted people are aged 60 and over. One in five people over 75 has a sight problem. Within the next 30 years, about 40 per cent of the UK population will be aged 60 and over, which means that 2.5 million people will be living with a visual impairment. Over two-thirds of those who are eligible are not registered as blind or partially sighted.
	There is strong evidence that adults in the UK are at risk of developing eye disease and other sight problems because they are not regularly having check-ups. Services have failed to pick up at least 1 million people with an eye condition which is either treatable or remediable, or which could be compensated for in some measure by rehabilitative services and equipment. Eight-five per cent of people over 65 who have cataracts and 75 per cent who have glaucoma have no contact with eye specialists. The number of overall sight tests since the extension of free eye tests to the over-60s has risen by only a small amount. People from certain ethnic backgrounds—for example, Afro-Caribbean and South Asian— are at greatly increased risk of glaucoma and diabetic retinopathy. One in five school-age children have undetected poor sight. People on low incomes are unaware of the exemption categories and low-income concession scheme and are not having sufficient eye tests. Further evidence can be obtained from a recent report from the Patients Association which demonstrates the inadequate information and access to treatments for major causes of blindness and visual impairment.
	The detection of eye disease and low vision happens at primary care level—critically, through the NHS sight test, which is also an eye health examination. But unless and until this matter is re-prioritised in local health strategies, and proper monitoring and targets are put in place for addressing under-identification and low take-up of services by at-risk groups, people will continue to lose their sight unnecessarily.
	The cost to the NHS of failing to re-prioritise eye health at primary care level will be huge. The risk of hip fracture is doubled in people with poor and moderately impaired vision. The cost to the National Health Service of treating sight-related falls and injuries among older people is estimated at £221 million, as against £25 million for rehabilitation and prevention.
	Amendment No. 159 seeks to insert a new clause setting up low vision committees. It would require,
	"each local authority in England and Wales; and ... each Primary Care Trust in England and local health board in Wales, jointly to establish and support a Low Vision Committee ... for the purpose of co-ordinating multi-disciplinary low vision services for persons with low vision".
	The purpose of the amendment is to ensure that low vision services become more uniformly available and are better co-ordinated across England and Wales. Low vision affects nearly 2 million people. Low vision services are crucial for rehabilitation, the prevention of accidents and the amelioration of general health. They depend on effective, patient-centred, inter-disciplinary working.
	There is a nationally agreed framework in England and Wales respectively for the way in which the disciplines can work together to provide effective care for people who lose their sight. However, without statutory provision for low vision committees, services will remain extremely patchy and unco-ordinated.
	What is a low vision service? It is a rehabilitative process which provides a range of services for people with low vision to enable them to make use of their eyesight to achieve maximum potential. It involves assessing the person's visual function. It involves providing aid, such as hand and stand magnifiers, telescopes, spectacle mounted aids, task lights and so on. It involves addressing psychological and emotional needs and facilitating modification to the home, school or work environments.
	Who provides these services? There are a huge range of practitioners involved in delivering them. Ophthalmologists undertake the clinical diagnosis; optometrists will be involved in low vision assessment, and often the provision of low vision aids. GPs need to be able to refer patients quickly. Rehabilitation workers and local societies for blind and partially sighted people provide advice, information, low vision aids and training. Other specialist practitioners need to be involved; for example, to deliver an effective children's low vision service. I could continue. There are a number of other professionals involved in the process.
	Research by the RNIB has found that more than half of the low vision teams contain only one type of professional group. One team in 10 has no link with any other agency. The amendment specifies that the membership of low vision committees must include a range of professionals such as the ones I have mentioned.
	Why is the amendment necessary? A lack of low vision services will mean more residential care and attendance costs for local authorities. Such a core rehabilitation service should be uniformly provided in the UK; but two out of every five potential service providers do not deliver any low vision services whatever, with some areas of the country left out altogether.
	Challenging AMD in Europe, a report from the AMD Alliance UK published in September, indicated that the UK was among the worst of the countries surveyed in providing rehabilitation services to people with age-related macular degeneration—the leading cause of sight loss in the UK.
	Current government initiatives relating to community equipment, pooling budgets and joint assessments—valuable though they are—will not make sufficient impact in this area because they are too generic and do not give a strong steer to PCTs and social services departments to prioritise low vision services. The National Assembly for Wales has begun to address the need for a low vision framework in Wales; but again, without any statutory requirement, services may be slow to develop.
	Three years ago, a report was published by the Low Vision Services Consensus Group, chaired by the noble Lord, Lord Jenkin of Roding. I am delighted to see the noble Lord in his place. It involved all the voluntary and professional interests engaged in these issues. Its central recommendation was for low vision committees to be established in every local area. A similar report was subsequently issued in Wales.
	The then Health Secretary commended the report to primary care groups, hospital eye departments, social services and voluntary agencies. If the Government still agree with every agency in the visual impairment field that low vision committees provide the best means of ensuring an integrated model of service, they should accept the amendment and insist that such a provision is written into the legislation. I beg to move.

Lord Jenkin of Roding: I completely agree with everything that the noble Lord, Lord Clement-Jones, has said—with the exception of his ever-generous reference to myself. I did not chair the committee that produced the recommendation, although I played some part in its being set up. Perhaps I may weary the Committee with just a couple of sentences of reminiscence.
	I had been invited to join the council of the Guide Dogs for the Blind Association in the late 1980s. That brought me into contact with a number of other national voluntary organisations for the blind and partially sighted. There was no machinery at all for trying to bring those bodies together, although many worked for the same ends. I set up and chaired for 10 years the visual handicap group, which consisted of those national voluntary bodies. We produced a report on better services for the visually handicapped, which was widely received and commented on favourably, not least by the Department of Health. We produced another report on the training of people to work with the blind and visually handicapped—an issue that had fallen through the wickerwork since the old blind workers disappeared with the Seebohm changes in social work.
	We also produced a report on low vision—the subject of Amendment No. 159. To many of us—this is not meant to be a pun—it was an eye-opener to see how inadequate services were across the country for people with low vision. Many patients who were examined by an ophthalmologist were simply told, "I am afraid that there is nothing more that medicine can do for you. You are going blind. Have you got somebody to take you home?". As the noble Lord, Lord Clement-Jones, said, it is a terrible shock for a patient to be told that they have an irreversible condition—although many people would now argue that some conditions are not as irreversible as they were once thought to be.
	We found that in many cases across the country there were virtually no services to pick up those people and make sure that they were given the help they needed. Some areas were lucky in having an effective voluntary organisation. A year or two after we produced our report, I was presiding over a meeting of the Wanstead and Woodford association for the blind and partially sighted. A consultant from Chelmsford told us what the Essex Voluntary Association for the Blind was doing. He spelt out almost exactly the contents of Amendment No. 159. That was being done in conjunction with the health authority and the local authorities. However, that situation was exceptional. I am not in the least surprised that the body that followed on from the visual handicap group—the body that the noble Lord, Lord Clement-Jones, referred to—came to the conclusion that something more positive is now needed to ensure that there are services to pick up and help patients who are diagnosed as having low vision. Many of them are elderly, but not all.
	I strongly support Amendment No. 159, because it seems to be the way ahead. I probably said when I was on the ministerial Bench that we already have a plethora of committees. I have some sympathy with that view, but I am convinced by the evidence that has been produced by Robin Birch and his Low Vision Services Consensus Group. The issue will be dealt with effectively only if every area has to have a low vision committee.
	I am not wedded to the full details of Amendment No. 159. It is a brave start, but the issue needs to be discussed fully with Ministers and other bodies to ensure that the provision is effective and workable and not too expensive. However, it is clear beyond peradventure that there is a need for something. The amendment gives us a chance to express a view in support of that. I hope that we shall do so. As the noble Lord, Lord Clement-Jones, said, those with a visual handicap have not been properly recognised in services. There are individual services such as sight tests and people can get glasses, but so much more needs to be done to allow those with low vision to be able to play their full role and develop their potential in the community and to allow old people to live independent lives. We need to address that. It is good that the amendment does so and I therefore warmly commend it.

Earl Howe: I have added my name to the amendments, which raise issues with far-reaching implications for the health service that I believe are of the highest importance for patients. I endorse everything that the noble Lord, Lord Clement-Jones, and my noble friend Lord Jenkin have said. It is difficult to overstate the extent to which eye disease and visual impairment impact on the lives of those so afflicted. As my noble friend has graphically described, to lose one's sight is a deeply traumatic event, which in many cases is a precursor to all kinds of misery, such as unemployment, state dependence and mental illness. As the noble Lord, Lord Clement-Jones, informed us, many people in this country are affected by uncorrectable sight loss and the numbers are growing.
	Much eye disease is treatable and preventable if caught early. However, compared with some other countries, we are not nearly as good as we should be in giving eye health appropriate priority at primary care level. Partly because the scale of the problem is not sufficiently appreciated, we tend not to be good enough at bringing information and help to those visually impaired people who need it.
	Information for the blind is not an add-on extra; it is an essential part of good quality care that can result directly in improved recovery from illness, the more effective use of health services and the avoidance of serious medical accidents.
	In recent years, there has been what I can only call an abdication by some health authorities and trusts of services tailored specifically to the needs of the blind or partially sighted. In the face of that, it is difficult to have confidence that PCTs will be able to establish any more creditable track record without a bit of gentle prodding. If the relevant services are to improve, we need to ensure that there are people tasked specifically with making the right things happen at local level. Low vision services committees provide an ideal mechanism for taking that mission forward. As we have heard, those committees emerged out of the very useful work of the Low Vision Services Consensus Group three years ago, for which my noble friend Lord Jenkin deserves a great deal of personal credit. Since then they have been encouraged by grant funding from the Department of Health.
	There are two elements to the rationale for those committees. One is to bring together all the key stakeholders in the delivery of services—doctors, ophthalmologists, social services, specialist workers, service users and others—so that everyone communicates properly. Without such grouping, there is inadequate co-ordination. The second might be called commissioning muscle. Users and voluntary organisations need to be assured that their voice will be heard and their needs will be fully taken into account by PCTs and local authorities when services are being planned. I am convinced that a statutory duty to establish and support those committees would make a huge difference to the current unsatisfactory pattern of services.
	What about providing accessible information to the visually impaired? The work of charities such as the RNIB in monitoring the provision of such services goes largely unsung. It should not be up to voluntary organisations to shoulder the task on their own. It should be done at national level, preferably by CHI. Health authorities and trusts are on the whole very dilatory about identifying those in need and having proper procedures and training. We need national benchmarks.
	For those reasons I urge the Government to take the amendments seriously. The Minister may say that these are essentially matters for local decision-making, but, as the noble Lord, Lord Clement-Jones, pointed out, the current mechanisms, such as pooling budgets, will not be enough on their own to do the trick, because they do not send out specific messages about the importance of low vision services.
	I hope that the Minister will at least reflect on the amendments in a positive spirit before Report.

Lord Hunt of Kings Heath: This has been a very interesting debate. I think that we are all at one in wanting to ensure that good eye care services are available throughout the National Health Service. I am very much aware of the recent survey by the Patients Association which suggested that provision of ophthalmic services is variable across the country and that, as the noble Lord, Lord Clement-Jones, said, eye care is not always seen as a priority by health authorities. I very much agree with the general sentiments that have been raised in this short debate.
	I have problems, however, with the suggestion that primary legislation is the route we should take to improve services. I also have problems with the suggestion that we should single out eye care services above all others to include in primary care legislation. I am sorry that the noble Baroness, Lady Cumberlege, is not with us today. In one sense, this debate seems to take us back to our earlier debate—which now seems a long time ago—on Clause 1 and the dilemma of developing policy and targets for the health service. The criticism in that debate was that the Government are setting the NHS too many targets, offering it too much guidance, and trying to constrain its functions and responsibilities in far too many ways. It is now being proposed that, in primary legislation, we should be very directional by telling the health service what it should do in particular spheres.
	Noble Lords' reasons for wishing to do that are quite understandable. I am sure that all noble Lords wish to see improvement in eye care services. However, I am sure that noble Lords will also appreciate that the more we seek to constrain the work of the NHS, the more we shall have a problem of too many targets and too many priorities. It is a dilemma. I should therefore like to explain in a little detail the Government's work on eye care services, and then deal with the work on developing the eye committees which have been established in various parts of the country.
	The Government's first action was to restore the free NHS eye test for everyone 60 and over, at a cost of £50 million annually. As the noble Earl, Lord Howe, suggested, that group is most vulnerable to eye disease and stands to benefit most from regular eye examinations. In 1999-2000, there were more than 2 million extra NHS sight tests, following the extension of eligibility for free tests. We are also taking steps to improve cataract services and have allocated an extra £20 million over two years to fund the capital costs of 60 schemes to improve treatment facilities and reduce waiting times. We believe that this investment will considerably improve the standard of eye care and greatly improve the quality of life particularly of older people. I am also glad to report that the number of NHS consultants in ophthalmology has increased by about 4 per cent in each of the past four years and will increase, from the current level of 651, to 895 by 2010.
	I therefore hope that noble Lords will accept that the Government are committed to ensuring that good standards of eye care are provided for the population. As I said, I am not at all convinced that this group of amendments would help to improve the position. I know that the noble Lord, Lord Clement-Jones, has corrected the amendment—which was new Clause 24—and that he intended to require that health improvement plans should include strategies for improving eye health and eye care services. That would require an amendment to Section 28 of the Health Act 1999, which places a duty on each health authority to prepare a plan that sets out a strategy to improve the health of those for whom they are responsible and the provision of healthcare to those people.
	I stress that health improvement plans—HIMPs—are strategic documents. We believe that, as such, it would be inappropriate for them to contain a lot of detail on specific activity in the health system. Surely it should be for localities to decide how to meet the identified priorities. I also question whether prescribing from the centre what HIMPs should contain would be contrary to the underlying principles of shifting the balance of power to the local level. All noble Lords seemed to agree with those principles when we debated them 10 days ago.
	The HIMP process has to work effectively. In future, local voluntary organisations, service users, carers and the public will have a greater role to play in the development of the HIMP. The Health and Social Care Act 2001 underpins the patient's and the public's involvement in the development of the HIMP. The Act places a duty on NHS bodies to involve patients and the public in the planning and development of services. We shall also eventually, although probably not tonight, debate the issue of patient forums which will be established for every trust. They will play a very valuable role in discovering what patients think about the quality of local services, monitoring quality from the patient's perspective, and working with the local trust to bring about improvements. That, too, will inform the local priority-setting and planning process.
	The position in Wales is similar. In line with the principle of devolution, the National Assembly will determine the form and contents of health and well-being strategies. The National Assembly intends to give advice about how the responsible bodies will work jointly to formulate and implement the strategy. The Assembly will also determine how prescriptive the regulations and guidance should be. Where possible, however, we hope that local partners are able to determine arrangements according to local priorities.
	New Clause 159 would require each primary care trust in England or local health board in Wales, and each local authority in both countries jointly, to establish a low vision committee for the area for which that primary care trust or local health board was established. As mentioned, a report in 1999 by a consensus group of organisations on the future of low vision services recommended the establishment of local vision committees for the purpose of ensuring that services in the UK are provided in accordance with the report's recommendations. I pay tribute to the noble Lord, Lord Jenkin, for his role in the establishment of that group. However, having seen him play a starring role last night in the parliamentary choir's performance of "Messiah", I realise that he has very many hidden talents.
	The Secretary of State for Health commended that report to the NHS and local government. As the noble Earl, Lord Howe, suggested, the department is contributing a grant of £120,000 over three years to provide an implementation officer from the voluntary sector to help in setting up local committees. Good progress is being made. My understanding is that, at the start of the year, 24 committees had been set up, and a number of others are under consideration. The noble Earl also suggested that some gentle prodding is needed. The implementation project is set to run for another 18 months. My view is that it would be inappropriate now to impose a requirement for primary care trusts and local authorities effectively to establish statutory low vision services committees. I think that it would make sense to allow the project to continue and for an evaluation of the committees' impact on service provision to be carried out by the implementation group at the end of that 18-month period.
	I would also caution against an overly prescriptive approach. It may be possible to have a good, multi-disciplinary, low-vision service without a formal committee. In some areas the primary care trusts may not always cover the area that is sensible in terms of linking and providing low-vision services, and other models may emerge. Under the present arrangement, the committee is not in the ownership of one body, and that emphasises the essential joint working, which would be important for the successful functioning of any of those committees.
	In the light of the debate tonight, the department will monitor what is happening and the progress by the implementation group. We already monitor the uptake of sight tests by eligible groups, and waiting lists. Sites that have been allocated funds for cataract improvement, for example, will also submit progress reports.
	We are represented on the low-vision services implementation group, which receives progress reports on setting up local committees at its meetings two or three times a year. In addition, there is a requirement for the group to make six-monthly progress reports to the department. I assure noble Lords that the department will continue to take a close interest in the progress of the implementation project. I take the view that legislation is not the appropriate route down which we should go, but I hope I have reassured noble Lords that we take a keen interest. I accept that having made progress in the past two or three years, more progress needs to be made.

Lord Clement-Jones: I thank the Minister for that reply which, in its latter parts, was positive and helpful. In one way it was the reverse of what I expected him to say. I thank the noble Lord, Lord Jenkin, and the noble Earl, Lord Howe, for their supportive comments. The noble Lord, Lord Jenkin, was clearly so enthusiastic and such a major contributor to the group that the people who briefed me thought that he chaired it. I suspect that that was a sign of his influence on them. I took the point he made that we should not expect to replicate best practice in a voluntary sense; we need an engine to spread it in a more statutory way.
	I turn to the points made by the Minister on the health improvement plan. If we are not careful, as the Bill goes through the House the Minister will accuse all those who believe in having a pro-active set of national standards of being centralisers. I do not believe that the essence of devolution is to simply wriggle about and say, "I'm sorry; this is not really something we can legislate for or be prescriptive about". "Prescriptive" is a weasel word which has perhaps come back to haunt this side of the Chamber. In the past, we have accused the Government of being over-prescriptive. But there is a median way. The detailed implementation in a decentralised system is a matter for the local primary care trust and the people on the ground. However, when it comes to stating national standards as to how one produces a health improvement plan and what it can contain, one can be entirely strategic in those circumstances.

Lord Hunt of Kings Heath: I am grateful to the noble Lord, Lord Clement-Jones, for giving way. I do not disagree with him when he says that it is right and, indeed, a duty for the Government to set the strategic framework in which HIMPs are developed. That is what we seek to do in the planning priorities guidance that we issue to the health service. That attempts to give a strong steer to the health service on the core priorities it needs to develop. I said earlier that Members of this place can raise a matter which they feel is important—we all agree that eye services are important—but the cumulative effect of treating every service with the same degree of priority would be to end up with a situation in which the health service is presented with 300 different priorities. As we have already discussed in our debates on Clause 1, that would mean ending up with a situation in which there are no priorities.

Lord Clement-Jones: I entirely accept that. I have read all the previous public health White Papers and Green Papers and know about the four key areas of government concentrations and so forth. The argument is not about setting priorities in those terms but about how many targets we set to try to get those priorities implemented. That is where some of the argument about micro-management is concerned. The setting of broad priorities for action is entirely satisfactory. Perhaps the essence of the argument today in terms of low-vision services is to try to push them higher up the agenda in the health service. That is an appropriate way to proceed. I detect that in the second half of his response the Minister accepted some of the argument in that respect.
	Therefore, it is not inappropriate to consider that health improvement plans should address that issue. We believe that they should cover a wide range of matters. Expecting them to cover this matter without stating the way in which they should deal with it or the priority it should be accorded is perfectly proper and an entirely strategic way to approach the matter.
	I turn to more positive ground. I believe that the Minister gave quite a lot of encouragement in response to the gentle prodding point raised by the noble Earl, Lord Howe. It would be inconsistent of those on this side of the House to expect PCTs, on top of all the other matters with which they have to deal—we have dealt with that in earlier parts of the Bill—to be over-prodded at this stage in terms of those services. However, I welcome the Minister's commitment that at the end of the 18-month evaluation period by the implementation group there will be a review to see how those services are developing, to see whether the voluntary approach has worked, and then to report back. It is important that the six-monthly progress reports are published and that there is proper dialogue with all the groups to which I have previously referred. That is a fairly formidable coalition. It is highly significant that that has now been formed.
	I take encouragement from the Minister. However, I believe that we may well need to return to the matter, depending on the evaluation that takes place after that period. We can always guarantee that there will be a health Bill passing through this place again. Even if we do not return to the matter on Report, we may well return to it in a future Bill. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	Clause 22 agreed to.

Baroness Noakes: moved Amendment No. 86:
	After Clause 22, insert the following new clause—
	"REPORT ON BODIES ACCOUNTABLE TO THE SECRETARY OF STATE
	(1) The Secretary of State shall prepare each year in relation to the bodies set out in subsection (2) a report dealing with the matters set out in subsection (3) and shall lay a copy before both Houses of Parliament.
	(2) The bodies referred to in subsection (1) are any body—
	(a) over which the Secretary of State has powers of appointment;
	(b) for which he provides the majority of its funding;
	(c) which he may direct as to the conduct of its business,
	but shall not include Health Authorities, NHS trusts or Primary Care Trusts.
	(3) The report shall contain in relation to each of the bodies referred to in subsection (2)—
	(a) its name;
	(b) the nature of the Secretary of State's relationship with the body;
	(c) details of the exercise of any of the Secretary of State's powers during the previous year;
	(d) the amounts provided to the body;
	(e) how the annual report and accounts of the body may be obtained; and
	(f) the Secretary of State's opinion as to the continued need for the body or, if he is of the opinion that the body is no longer needed, how he plans to proceed."

Baroness Noakes: Amendment No. 86 inserts a new clause after Clause 22 dealing with the various bodies for which the Secretary of State has responsibility.
	At Second Reading, the noble Lord, Lord Walton of Detchant, who I am sorry is not in his place, spoke about the Government suffering from "quangoitis" and being determined to convert the NHS into a "quangocracy". It seems that the Government's instinctive reaction to any problem is to set up one or more new bodies. Since 1997 they have created a long list of bodies: the Human Genetics Commission; the Genetics and Insurance Committee; the NHS Information Authority; the Commission for Health Improvement; the National Institute for Clinical Excellence; the Health Development Agency; the NHS Purchasing and Supply Agency; the NHS Logistics Authority; the General Social Care Council and its equivalents in Scotland, Wales and Northern Ireland; the National Care Standards Commission; and the National Patient Safety Agency. There are probably others which I have missed.
	In this Bill alone we have a multitude of patients forums, far more than the CHCs which they will replace. We have the Commission for Patient and Public Involvement in Health and the council for the regulation of health care professionals. Since the Bill has been published, the Government have announced, in their response to the Bristol report, the setting up of a council for quality of healthcare. In January, the Chief Medical Officer announced a new national infection control and health protection agency. Only a week or so ago the Secretary of State announced a new board of patient choice trustees. There is no sign that the Government's zeal for new quangos is diminishing.
	I am not seeking to debate the merits of any of those bodies individually. The amendment merely asks for an annual report setting out who the bodies are, their relationship with the Secretary of State, the money provided to them and where their annual report and accounts may be obtained. Importantly, the report should also give the Secretary of State's opinion as to the continued need for the body. If nothing else, it would be an opportunity for the Secretary of State to reflect on the size and nature of his quango empire. It would also give both Houses of Parliament the opportunity to consider the issue too.
	I am aware that much of this information is already available in other places, for example, in an annex to the Department of Health's explanatory plans and information on the Cabinet Office website. The aim of the amendment is to bring together all relevant information relating to the Department of Health once a year and, crucially, to ask the Secretary of State to give his views as to the continued need for the bodies. That, in turn, would approve the accountability of the Secretary of State for the bodies that he has created. I hope that the Minister is in favour of increased accountability and will support the amendment. I beg to move.

Baroness Masham of Ilton: I support the amendment as it is an exceedingly good idea. I went to the launch of a new body last night. It was launched most eloquently by the Minister. It was to do with safety, but I cannot remember the full title.

Lord Hunt of Kings Heath: It is the National Patient Safety Agency.

Baroness Masham of Ilton: That is a most important issue and I am sure that the agency will grow. It would be useful to have a list of quangos, as it is useful to know how important they are. On matters such as the control of infections in hospitals, for example, we could see how they were doing and the progress on all sorts of issues such as food and so on. The amendment is an excellent idea which I hope the Government will support.

Baroness Pitkeathley: I cannot see the need for this information because it is already available. I was not sure whether the noble Baroness wanted more information, different information or more information in a different form.
	I currently chair a non-departmental public body which is sponsored by the DCMS, and I am the former chair of a Department of Health-sponsored body—the GSCC. My experience is that NDPBs and all other bodies already produce huge amounts of information, all of which is available to the public. They are required by the Secretary of State to produce strategic plans, business plans, annual reviews and they must meet all kinds of performance targets, including administration costs.
	Clearly they are responsible to Parliament through the Secretary of State. Their boards are appointed through open advertisements by an independent panel and then approved by the Secretary of State. In terms of justifying their continued need, I believe that adequate information structures and systems already exist. I am reluctant to see further requirements being imposed on them, so that they have to spend more time reporting than doing the job that they were set up to do.

Baroness Carnegy of Lour: I agree with the noble Baroness about that, but the point of the amendment is probably that it is very much easier to set up a quango than to close it. I do not know whether the noble Barones has ever chaired anything that the Secretary of State tried to close. I have, and the Secretary of State did not close it. It is really quite difficult to shut something down.
	We cannot have an ever-expanding empire when some bodies have passed their sell-by date. Whether or not the amendment is the right way to do it, the point is that subsection (3)(f) would require the Secretary of State to say whether the body was still necessary and, if not, what he will do about it. He has to say it with the knowledge of Parliament because the matter will be laid before Parliament. That is the point of the amendment, and if some way could be found to keep that requirement, it would be very helpful. A mushrooming of quangos is not a good idea if some of them are no longer necessary.

Lord Hunt of Kings Heath: Clearly we do not want unnecessary quangos. I accept that, and it is important that all the activities of non-departmental bodies are kept under close review. If evidence arises that the job can be done better by other means, or that certain bodies are no longer required because life has moved on, I am all in favour of bringing their activities to an end.
	The Government have looked at many non-departmental public bodies and have made changes. For example, we debated the proposals of the Chief Medical Officer on Monday on the surveillance and public health arena. It is proposed that one agency should be established in place of four existing agencies. There are other examples of the Government looking at rationalising non-departmental public bodies.
	It is also significant that a number of the bodies to which the noble Baroness, Lady Noakes, referred—the noble Baroness, Lady Masham, also mentioned the National Patient Safety Agency—carry out important functions in terms of national standard setting. I am thinking about NICE or the Commission for Health Improvement investigating the quality of services at local level, or the National Patient Safety Agency to which National Health Service organisations will report adverse events. From that reporting, we hope to learn ways of improving the quality and safety of healthcare services. Those are important matters that need to be dealt with.
	I would also argue that, having established such national bodies, enabling us to develop national standards, to which the noble Lord, Lord Clement-Jones, referred in the previous amendment, we are then in a much better position to decentralise. We can allow, within that national framework setting, National Health Service organisations at local level to have a much greater ability to decide their own destiny. Throughout the Bill we shall continually debate the balance between national standard setting and local determination. I am convinced that the establishment of a number of agencies at national level will allow us to decentralise more decision-making to local level.
	I also agree with the noble Baroness, Lady Noakes, that openness about the roles and responsibilities of non-departmental public bodies is desirable in health, as across government generally. The Government's wish to promote increased accountability and openness for all quangos led to the publication of the measures in Quangos: Opening the Doors. Considerable progress has been made in this area in the past four years.
	As my noble friend Lady Pitkeathley suggested, there does not seem to be much point in publishing again, in another format, information about the Department's quangos that is already available from other sources. The noble Baroness, Lady Noakes, mentioned the Cabinet Office's annual publication, Public Bodies, which already contains the majority of information dealt with by the amendment, including that for all the Department of Health's non-departmental public bodies.
	In addition, the bodies themselves publish their own annual reports, including on the Internet, which gives that much more detail than is contained in the Cabinet Office's publication. Ministers remain accountable to Parliament for non-departmental public bodies. That includes informing Parliament about decisions relating to the reviewing and abolition of such bodies. It is notable that the Select Committees of your Lordships' House and in another place frequently examine the performance of those non-departmental public bodies. They frequently call in the chair and chief executive of those bodies for what can only be described as fairly searching examination. In addition, if the Secretary of State were to issue any written directions to these bodies, that fact would be published in the department's annual report. We would expect that the bodies concerned would wish to make a similar statement in their own annual reports.
	I am convinced from my own experience in dealing with a number of the bodies mentioned in the debate that each of those bodies is under no illusion that we consider it very important that they are open about their activities; that they constantly examine the work that they do; and that they are encouraged to ensure that reports about their activities are published and put into the public domain. On that basis, I do not think that the amendments, while I understand their thrust, are necessary.

Baroness Noakes: I thank the Minister for that response. I thank the noble Baroness, Lady Masham of Ilton, and my noble friend Lady Carnegy of Lour for their support for the amendment.
	In tabling the amendment I was trying to draw attention to the multiplicity of the created bodies. The Minister referred to the 2001 publication, Public Bodies. It shows that the Department of Health had at that time 69 bodies. The number is sure to have increased since then. The empire is growing. I understand and do not dispute that having certain kinds of agencies could lead to the ability to support further decentralisation. Indeed, at this stage I am not seeking to dispute the merits of any one of the bodies that I have mentioned or any one of the 69. My point was to draw attention to the increasing number of bodies and the increased use of non-departmental public bodies to undertake functions at the core of the Department of Health.
	I am grateful to the Minister. I shall think carefully about what he has said. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	[Amendment No. 87 not moved.]

Lord Clement-Jones: moved Amendment No. 88:
	After Clause 22, insert the following new clause—
	"NHS REGISTERED MEDICAL PRACTITIONERS
	In respect of registration of persons proposing to practise in the National Health Service, section 19(3)(a) of the Medical Act 1983 (c. 54) (full registration of persons by virtue of recognised overseas qualifications) shall apply as though the words "other than the United Kingdom" are omitted."

Lord Clement-Jones: Amendments Nos. 88 and 89 are quite closely related amendments. They spring from a perception of the minefield that any UK citizen who qualifies in a medical school abroad has to step through before he or she can practise in this country.
	Amendment No. 88 deals with the International English Language Testing System, the IELTS. Section 19(1)(b) of the Medical Act 1983 stipulates that an applicant for full and provisional registration must satisfy the registrar of the GMC,
	"that he has the necessary knowledge of English".
	IELTS was adopted as a means of assessing linguistic proficiency following a recommendation from a Department of Health working group. It assesses skills in reading, writing, speaking and listening to English. But nationals of the EEA member states, other than the United Kingdom and others with what are called "enforceable EC rights", are exempt from having to demonstrate proficiency in English as a result of amendments to the Medical Act 1983.
	The GMC admits that it would prefer to test EEA nationals but it is illegal to do so because EU laws prevent discrimination against EU citizens on the basis of language. Therefore, the people who have to take the test are by and large any UK citizen who qualified outside the EEA and any non-EU citizen who qualified outside the UK. That means that someone who is British but has trained outside the EEA—loosely speaking the EU, but slightly wider—has to take an English language test. That is rather an absurd anomaly that our amendment seeks to get rid of.
	It should be noted that there is actually no legal requirement for a Briton who has trained outside the EEA to take the language test. It was the GMC's decision to adopt the language test. It is not mentioned as such in the Medical Act. All that is legally required is for the GMC registrar to be satisfied that a test would be a waste of time and money. So it would be possible for the GMC in these circumstances to get rid of the IELTS requirement.
	I do not know whether the Minister has had the opportunity to look at the table produced by the GMC of the tests that are required. The table covers both the PLAB and the IELTS tests. It is almost completely incomprehensible to a lay person. Therefore, we have this absurd situation which I have outlined. We also have the potentially problematic situation of an EU national—no matter where in the world he or she qualified—who speaks no English at all, starting a job in a British hospital without taking any kind of language assessment. It is not possible to get rid of this because of the EU anti-discrimination aspect, but at least we can get rid of the situation where a UK citizen has to take the test even though English is his first language. The amendment would change that situation so that UK citizens would not have to take the language test no matter where they trained.
	I move to the second amendment and turn to the PLAB exam. I want to use the example of a medical school that is well known to many Members of the Committee. I see that the noble Lord, Lord Soulsby, is in his place. I know that a number of noble Lords have connections with St George's University School of Medicine. I want to use it as an example of some of the problems that arise as a result of current requirements.
	St George's University School of Medicine is 25 years old. This international school boasts an extremely high standard of education for medical students from the USA and from some 30 countries in the world. The standard of success of students can be measured by equating the results of the intermediate examinations which have to be undertaken by American students—currently, 70 per cent of students come from America—compared with USA standard schools. Last year, the results of the two examinations show that St George's has an equal if not improved pass rate in these relative exams. Basic sciences are taught on the islands of Grenada and St Vincent. Following that, students have an option of completing their clinical training either in the USA or in the UK.
	What then follows for students who have qualified at St George's University and who then want to practise in the UK? They are able to come and practise in the UK in two ways. First, they must pass what is called the UEB examination. That examination is set and examined by the Society of Apothecaries. Hitherto students who wished to take the examination were assessed by certain UK universities. Having been signed off by the local dean as satisfactory, students were permitted to take this examination. Passing it gave the students registration with the GMC to work in the UK.
	The second method of being able to practise in this country is taking and passing what is called the PLAB exam. That examination is set and examined by the GMC and consists of a theoretical and practical examination. In addition, all doctors applying for limited registration with the GMC must have obtained a satisfactory score, as I described earlier, in the academic modules of the IELTS.
	The UEB examination in its present form will be changed dramatically. It will not, it now seems, be applicable to St George's students. All students from St George's have been told that in future they will have to take the IELTS and PLAB examinations in order to practise medicine in the UK.
	So the spotlight then turns on to PLAB and the requirements for taking that exam. Older, traditional Commonwealth universities whose students have automatically received full registration in the UK include countries like South Africa, Australia and New Zealand, and the University of the West Indies. They were not required to take the PLAB exam. But the GMC has intimated that it wishes to discontinue with this so-called "élite" group of universities to level the playing field, so that overseas applicants who wish to work in this country will all have to take the PLAB examination.
	It seems rather topsy-turvy to get rid of this group. One may not think that it is appropriate to have a specific élite group of universities drawn from a very narrow group of traditional universities, but we on these Benches, together with St George's University, feel that the standard of medicine as taught by the medical school at St George's is such that it is at least equal to this élite group.
	Instead of disbanding that group as giving automatic exemption from PLABs, it should be increased so that a number of international medical schools with sufficiently high standards, as approved by the GMC, are able to gain full registration. The reason is that we have an acute shortage of doctors in this country. The Government are trying to increase the number of medical school places but that will take time. Meanwhile, 10,000 new GPs are needed and another 7,500 home-grown consultants by 2004—the Government's target. All that the Government are doing in recruiting consultants abroad will not plug the gap. To meet present contractual arrangements, an extra 3,500 physicians are needed at this moment—which does not include any consideration of the working time directive.
	Along with other medical schools world-wide, St George's University School of Medicine has the capacity and expertise to train UK students who are unable to start training, perhaps because of a lack of available slots in the United Kingdom. It seems sensible to bring some order to the process whereby UK students do not have to take the IELTS and the PLAB if their medical school is of a sufficient standard. I hope that the Minister will consider the amendments, perhaps discuss the subject with the GMC and look favourably on the principles involved. I beg to move.

Baroness Carnegy of Lour: I realise that the noble Lord was talking beyond the European Union but I recollect serving on an inquiry about an EU directive which determined that while member states may have to accept individuals working in a particular profession, they may set the standards required. The list of qualifications to which Amendment No. 89 refers would exist for that purpose. Speaking English is obviously a requirement for anyone working in this country. Did not the GMC bring that aspect into the consultation?

Lord Clement-Jones: The amendments are not directed at a UK citizen practising within the EU as regards PLAB but only as regards the IELTS.

Baroness Carnegy of Lour: But presumably a European Union citizen practising in this country would be affected by that directive.

Lord Clement-Jones: The two amendments only relate to UK citizens, not to cross-border working by EU citizens outside the UK.

Baroness Carnegy of Lour: I apologise. I misunderstood.

Lord Soulsby of Swaffham Prior: I support the noble Lord's two amendments. I declare an interest as a member of the academic board of St George's University.
	The noble Lord clearly explained the intricacies of British graduates returning to this country from medical schools overseas. In the past, I have been associated with the University of the West Indies. Graduates from that university's medical schools on three islands can come to this country without let or hindrance in many ways. It is anomalous that graduates of a school in Grenada of equal quality cannot do so.
	By virtue of the fact that we are short of medical graduates, one could at the stroke of a pen increase the number available and the number going for training. St George's is already set up. If the amendments were carried, it is likely that a greatly increased number of British graduates would take a medical degree at St George's University.
	I remind the Committee that the medical programme at St George's is to take the pre-clinical and some of the para-clinical teaching in Grenada. Then the clinical students are farmed out to selected clinical departments in the United States and this country. There is of course a tendency for the United States students to go to the US and for the British students to come here. When graduation takes place, we have British graduates who have been trained at clinical level in British medical schools. Consequently, they are entirely familiar with medical issues, programmes and problems in this country. Such a development would certainly be convenient to the medical profession in terms of supplying well-trained graduates for our health service.

Baroness Howells of St Davids: I support the noble Lords, Lord Clement-Jones and Lord Soulsby. I am confident that my noble friend the Minister is aware of concerns that the provision in question exists for one purpose only—to discriminate unfairly against individuals who obtain their medical degrees outside the so-called white Commonwealth. I understand that the GMC is concerned about that distinction at a time when we freely speak about globalisation. I trust that my noble friend the Minister will undertake to look again at that suspect wording because I understand that the GMC would like the distinction abolished.

Lord Filkin: The amendments raise interesting and important issues in the context of the NHS seeking to ensure an adequate number of trained professionals.
	It has been recognised in statute for some years as right and necessary that the GMC should satisfy itself about the English language ability of a person who qualifies in medicine overseas. The only exception is our treaty obligation to our European partners to allow freedom of movement by EU nationals. That does not mean that a French doctor would be able to practise in the UK if his English language skills were poor. He would have a right to register with the GMC but it would still be perfectly possible for a health authority or health trust seeking to employ such a person to satisfy itself that he was suitable by having adequate fluency in English. We need not be fearful that the measure is leading to something grossly inappropriate.
	To be fair to all who apply for registration, it is right that the GMC must have a rule of some kind and that it should have as few exceptions as possible. For example, the rule should apply also to people who are British citizens. One can imagine cases where a British citizen emigrated at a young age and may not have the facility in English needed to be a doctor in this country. The GMC wants to be as helpful as possible, both to be fair and because it appreciates the value to the UK of people with overseas qualifications who want to work here. While we do not think that the amendment is the right route, it may be helpful to get the GMC to reconsider how it satisfies itself under its obligations of English language ability. The standard test may not always be necessary, but that is a matter of GMC policy rather than law. I understand that the GMC will follow carefully today's debate and take from it lessons for consideration.
	The new clause is also wrong to confine itself to people wanting to work in the NHS. There should be one standard for registration, regardless of a person's intended employment in health professions. So while I cannot support the amendment, I understand the sentiments that motivate it and hope that a solution can be found as I have suggested. If the Government were persuaded in future, in the light of fuller consideration by the GMC, that a change in the law was necessary, an order under Section 60 of the Health Act 1999 would provide an appropriate vehicle.
	The noble Lord, Lord Clement-Jones, is correct to say that there is no legal requirement for a British citizen to take a language test. The Act requires that the registrar of the GMC is satisfied that applicants—including British citizens, unless they have EU rights—have the necessary knowledge of English. The test itself is not a requirement of the Act.
	The noble Baroness, Lady Carnegy, raised the issue of the directive. We think that it is probably the directive on the mutual recognition of medical qualifications. No, it is not. We shall keep searching.

Baroness Carnegy of Lour: I am sorry for raising the matter without having checked it. I thought that it might be helpful to ensure that the Government had considered that in replying to the amendment. I am sorry if I have wasted the Committee's time.

Lord Filkin: We shall have a further opportunity to reflect on that and, if appropriate, give a subsequent answer. We will of course need to check the specific relevance to the issues we are discussing today.
	Amendment No. 89 is also unnecessary. It would compel the GMC to maintain a list of recognised overseas qualifications. As the Committee will know, the GMC already does so and I am unaware of any case in which people seeking a registration or wanting to check a doctor's registration have had any difficulty getting the GMC to share the list with them.
	However, this is a good point at which to say something about the substantive issue of recognised overseas qualifications, which several Members of the Committee have raised. There have been concerns that provisions of the Medical Act 1983 discriminate unfairly against those who obtained their medical degrees outside the so-called white Commonwealth. My noble friend Lady Howells was clear on that point. The GMC would like that distinction abolished and, broadly speaking, we share its view. It proposes—and we support it—to abolish the status of recognised overseas qualification that degrees from 22 universities currently hold. Graduates from those universities will then be in the same position as those from the hundreds of other institutions world-wide whose medical courses are recognised by the World Health Organisation. They would have to demonstrate their competence at the point of registration—as do graduates from the United States or, say, India, currently.
	The Government, in the light of the GMC's consideration, will use the next suitable Section 60 order to make the necessary amendments. Discussions with the GMC have already begun on that, and we plan to lay the order before Parliament later in 2002 after full consultation in the normal way.
	Some important points were raised about St George's. My noble friend Lord Hunt recently met representatives of St George's Hospital and a group of hospital friends in the UK. He has asked departmental officials to consider the issues raised. He recognises the potential and quality of the medical education at St George's. While the Government's approach is not exactly the same as that proposed by the noble Lord, Lord Clement-Jones, in Amendment No. 89, we feel that it is an appropriate manner in which to proceed. It will ensure that there is no unfair discrimination and that suitably qualified medical people are able to practise in the UK. I urge the noble Lord to withdraw the amendment.

Baroness Masham of Ilton: Before the Minister sits down, perhaps I may ask him whether the provision includes doctors from South Africa.

Lord Filkin: I am fairly certain that the system that I described would apply to doctors from all around the world, and would therefore include those from South Africa.

Lord Clement-Jones: I thank the Minister for his reply, which, as he said, was not entirely in line with what I want. I thank the noble Lord, Lord Soulsby, and the noble Baroness, Lady Howells, for their support for the amendments. They seek to ensure that we make the best of a potential pool of properly qualified, well-trained graduates and that there is no discrimination in favour of white Commonwealth universities—a phrase used by both the Minister and the noble Baroness. It is important that we are not in the business of levelling down. That is where the current GMC proposals and what the Minister had to say are unsatisfactory.
	I understand the issue about the IELTS. It may well be possible to persuade the GMC not to apply it to UK citizens. I take the Minister's point about it being up to hospital trusts to vet their doctors, but there is considerable pressure on trusts to take on doctors. If they are already registered on the basis that they have a somewhat rudimentary knowledge of English, it is difficult not to accept them. The essential check is on registration, and UK citizens are being required to take a language test at that point. That seems rather anomalous.
	I agree with the Minister that it is perhaps not entirely appropriate to legislate on the matter, but he then went on to say that a change may be made by regulation under Section 60 of the Health Act 1999.

Lord Filkin: I thank the noble Lord for giving way; perhaps I can remark on one or two points. First, British citizenship is not a guarantee of adequate fluency in English. Secondly, a health authority or trust would be grossly irresponsible if it sought to employ someone who did not appear to be sufficiently fluent to carry out his medical duties. There is no more to be said on that. They must act responsibly; they are public protectors. We should rest with comfort that those people treat those responsibilities seriously. Finally, after due consultation, the House will have an opportunity to consider any proposed order, as is right and proper.

Lord Clement-Jones: I thank the Minister for that clarification. But what is sauce for the goose is sauce for the gander. If we believe that hospital trusts have the appropriate mechanisms to vet those doctors who have been registered and apply to them for vacancies—in other words, that they are capable of assessing their language skills—why should that not apply to UK citizens as well? UK citizens are labouring under a disadvantage. If citizens of Italy or France do not have to take the IELTS and we rely on the hospital or trust to vet them, why cannot we do the same for UK citizens, who, percentage wise, have a far better chance of speaking English? The Minister has made my case in his intervention.
	Secondly, the GMC may be barking up the wrong tree. I have had some discussions and I believe that the levelling-down point is important. To say that the concept of an élite group of white Commonwealth universities whose product is regarded as fulfilling the requirements and, ipso facto, does not have to take the PLAB exam is clearly discriminatory and therefore should be abolished seems to be going in the wrong direction. There should be a broader, more inclusive group of universities, such as St. George's, which I described, which qualify as far as the GMC is concerned and whose graduates are not required to take PLAB.
	This is a minefield. We must recognise the quality and potential of individuals coming out of those universities. That would best be done by exempting them from the PLAB examination. The purpose of encouraging UK citizens to take up places at those high-quality universities is lost if there is the major disincentive of two hurdles to overcome: first, the IELTS, and secondly, the PLAB. I could quote examples of constituents of honourable friends in the other place, who have been offered jobs in hospitals but find that they are unable to find a place for a test. Therefore the hospitals lack their presence and in some cases such doctors may lose their jobs due to the bureaucracy of the exams and the shortage of time or place for them to sit them in order to qualify.
	That is a significant disincentive for a young student considering where he is going to qualify and undergo his medical training. A good deal more discussion needs to take place. The passage of the Bill may not be the best place for it, but the airing of the subject today has been valuable. I thank the Minister for his consideration and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	[Amendment No. 89 not moved.]
	Clause 10 [Expenditure of NHS bodies]:
	[Amendments Nos. 90 and 91 not moved.]
	Clause 10 agreed to.

Baroness Noakes: moved Amendment No. 92: After Clause 10, insert the following new clause—
	"REGIONAL STRUCTURE
	(1) If in any year the Department of Health has directors of health and social care who have regional responsibilities or if it has regional offices, regional directors or any other regional structure, the Secretary of State shall lay before both Houses of Parliament each year a report containing the matters set out in subsection (2).
	(2) The report shall contain—
	(a) the names and qualifications of the relevant directors;
	(b) the geographic regions covered by the relevant directors;
	(c) a description of the functions, responsibilities and accountabilities of the relevant directors;
	(d) the number of staff reporting to the relevant directors and details of the functions of those staff;
	(e) details of the premises occupied by the relevant directors and their staff;
	(f) the total cost of the work of the relevant directors and their staff;
	(g) a description of the relationship between the relevant directors and the National Health Service trusts, Primary Care Trusts and Strategic Health Authorities within their regions;
	(h) a description of the relationship between the relevant directors and the Secretary of State;
	(i) a description of the targets or objectives which have been set for the relevant directors and their staff for the year which is covered by the report;
	(j) a description of the manner in which the relevant directors and their staff have conducted their functions during the year, including whether they have met the targets and objectives set for them; and
	(k) a description of the targets or objectives which have been set for the relevant directors and their staff for the following year.
	(3) In this section "relevant director" means a person who is designated a director of health and social care with regional responsibilities or a person who is in charge of a region, regional office or other part of a regional structure of the Department of Health."

Baroness Noakes: The amendment seeks to introduce an annual report on the activities of the new directors of health and social care and any other regional directors that exist or may exist in the future. In the days which some of us now refer to as "the good old days", there was a regional tier in the NHS. There were 14 regional health authorities with full boards and local accountability. For good reasons, that tier was largely removed in the 1990s, although many of the activities formerly carried out by the staff of the RHAs continued to be carried out under a new guise, with the staff becoming the eight regional offices of the NHS Executive, each led by a regional director.
	Now the regional directors have disappeared, or are in the process of disappearing, and there are four directors of health and social care covering four areas of the country, although I understand that the regional offices will not disappear until March 2003.
	Although not called "regional directors", these directors carry regional responsibilities. They are described on the Department of Health's website as being,
	"4 Regional Directors (who) will provide a link between the Department of Health and the frontline NHS and social services".
	That link is important and needs to be made transparent.
	I know that on our first Committee day the Minister was at pains to say that the new directors of health and social care are not an extra tier in the NHS but are really a part of the NHS headquarters—a sort of headquarters in the country. Amendment No. 92 does not rest on whether that is a tier as such. It rests on the very existence of the posts which have a potentially significant role in how the NHS operates in practice.
	The directors of health and social care have the potential for great influence within the NHS. They generally operate out of the public eye, but occasionally we get a glimpse of what they do. A recent example is a letter written by Mrs Carnall, the director with responsibility for the South, who told her health authorities and trusts that a projected £60 million overspend was "totally unacceptable" and that they must find "solutions". I ask the Minister in whose name the regional directors describe matters as "totally unacceptable"? We have to assume that they speak on the Secretary of State's behalf. That is why we need to see what they do and how they do it.
	There is a description of the activities of the four directors in Shifting the Balance of Power, but it is difficult to see these activities providing much for the directors to do, let alone the 40 staff that each of them will have, and that number excludes staff who will work for the regional directors of public health. But "trouble shooting" is listed as one of the roles. Will the directors troubleshoot strategic health authorities, primary care trusts, NHS trusts, general practitioners, or all of those? What powers will they have? How will they in practice carry out their tasks?
	Many questions can legitimately be asked about the four directors. Amendment No. 92 seeks to put some basic facts into the public domain about the directors, their staff, what they do, how they do it and how much they cost. I see that information as shedding light into a corner of the Department of Health which has become obscure over the years. It will provide a good springboard for the Health Select Committee in another place to look at what the directors do and it may also provide an opportunity for your Lordships' House to debate the role and function of that part of the NHS.
	But it is not only the relationship of the directors to the NHS that is important. The Local Government Association has expressed its support for the amendment as,
	"one way of tackling the lack of clarity that currently exists in relation to the social care remit",
	of the directors. It has welcomed the opportunity for parliamentary scrutiny.
	I hope that the Minister will clarify the role and purpose of the four new health and social care directors and describe how they relate to the existing regional offices. I hope that he will also describe how and to whom they are accountable. I hope that he will welcome the increased knowledge of their work which would come about if the amendment were accepted. In the interests of transparency, I beg to move.

Lord Smith of Leigh: I share some of the concerns of the noble Baroness, Lady Noakes. However, she is looking in the wrong direction to some extent. We should be looking at the role regional authorities can play in England in managing matters themselves. The noble Baroness is right that those bodies could have influence in the regions. Health matters and decisions about spending affect local areas significantly. They affect employment, regeneration and other matters important to the regions. It is vital that regional health strategies meet the strategies of other bodies that affect the regions.
	Regionalism in England is on the march. Regions are beginning to recognise what they are missing out on. A BBC opinion poll in my region of the North West today states that 72 per cent of people would welcome the setting up of devolution in England. In answering the question, I hope that my noble friend will assure us that once devolution for England is proposed in the forthcoming legislation, health in those areas will not be forgotten. Meanwhile, I hope that the health bodies will talk to their regional partners to make sure that the strategies line up.

Lord Clement-Jones: That was fighting talk from the Back Benches opposite. It is great to see such support for regionalism from the Government Benches. Sometimes one does not see quite the same level of enthusiasm from the Front Bench.

Lord Hunt of Kings Heath: I shall pass on the issue of regional government, though I warm to the noble Baroness's sentimental look back at the good old days of regional health authorities. I am beginning to think she should form an annual dinner where we meet to celebrate the past successes of those wonderful organisations.
	Of course, it was the previous government who removed the old regional authorities, set up regional offices and then kept this rather peculiar role and office of regional chairman to straddle alongside the regional offices, which frankly did not work. I note also that the previous government did not feel it necessary to put into place the kind of reporting mechanism which the noble Baroness is suggesting today.
	I want to make it clear, as I did in our earlier debate, that these directorates of health and social care are headquarters directorates of the Department of Health. It would not be appropriate for them to be the subject of separate processes of annual reporting.
	I know the noble Baroness, Lady Noakes, disagrees with me about the significance of those directorates not being a separate tier of the NHS. But it is an extremely important issue. The four directorates of health and social care are members of the Department of Health's management board. They will between them have the main responsibility for working directly with the NHS and performance managing strategic health authorities.
	That role will involve the oversight and development of health and social care, ensuring that local health and social care communities are developed in an integrated way to deliver modernised services and supporting the Chief Executive and the Chief Inspector of Social Services at the Department of Health in assessing the performance of the whole system. In public health, the director for health and social care will have a regional director of public health and public health team co-located with each government office. I have already made clear that the regional directors of public health will be jointly accountable to the directors of health and social care, and to the Chief Medical Officer. They will be managing, as part of a national programme, the appointment, development and succession of senior management staff. They will be supporting Ministers through casework, ministerial visits and local intelligence.
	As the noble Baroness said, they will deal with troubleshooting. I am fairly clear what that means. It means getting involved when things look as though they are going wrong; banging heads together—as the noble Baroness will be aware, I am very keen on that—and dealing with issues as they arise within the region for which they are particularly responsible. In the first instance they play a major role in developing the new organisations, maintaining close involvement, whenever necessary, with strategic health authorities and focusing very clearly on performance management.
	The noble Baroness, Lady Noakes, asked a number of questions about the specifics of how it will all work, or at least her amendment seeks to adduce that information in the fullness of time. First, she is right that regional offices will not be formally wound up until March 2003, but the new directors start their work formally from April this year. The 12-month period is merely a transition to deal with any overlap. Obviously we want to avoid any duplication of effort between the regional offices and the new directors.
	In 2002-03 the running costs will amount to roughly £30 million rising to £34 million in the next two financial years. Clearly a number of matters have not yet been settled and I would not want to be held exactly to those figures.
	The other point I would make is that those people are national directors. As I said, they have seats on the departmental board and we will expect them, alongside their regional responsibilities, to contribute to national work as well. It will be quite likely that a director of health and social care will also take on lead responsibility for national work as well. That reinforces my point that this is not an additional tier; these are merely senior officials of the Department of Health with specific responsibilities as part of their duties for a specific region in England. Accountability is quite clear. They will be accountable to the Chief Executive and Permanent Secretary of the Department of Health.
	From what I have said, I hope that Members of the Committee will agree that it would be inappropriate to single out just four members of the management board of the Department of Health for special treatment in that way. I invite the noble Baroness therefore to withdraw her amendment.

Baroness Noakes: I thank the Minister for his reply and for the information contained in it.
	Perhaps I should say at the outset that, though I was grateful for the comments of the noble Lord, the amendment was not tabled with any zeal for regionalisation, as he might imagine. It was tabled with a zeal to understand the interface between the Department of Health and frontline NHS and social services, to use the language of the department's website.
	I hear what the Minister said as to what will be happening. It will be interesting to see how it works out in practice, which is why the amendment was moved. I hear what he says about this not being a tier, though that is not important. What it encourages me to do is to look at the information available as to what all members of the Department of Health management board do; perhaps it should not be confined to these four directors of health and social care. More light perhaps needs to be shed on the workings of the management board in general. I should like to think about that further. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Lord Filkin: I beg to move that the House do now resume. In moving this Motion, perhaps I may suggest that the Committee stage of the Bill begins again not before 8.37 p.m.

Moved accordingly, and, on Question, Motion agreed to.
	House resumed.

Social Security Administration Act 1992 (Amendment) Order 2002

Baroness Hollis of Heigham: rose to move, That the draft order laid before the House on 28th February be approved [22nd Report from the Joint Committee].

Baroness Hollis of Heigham: My Lords,this draft order is technical in nature so I shall be brief. It makes changes to the list of organisations that will be liable to provide information to the department and to local authorities for the purposes of combating benefit fraud. But it does not add any new categories of organisations to the list. It makes some changes to the definitions of organisations included, to bring them in line with current legislation, and it clears up some uncertainties and omissions from the original list, for the sake of clarity and the avoidance of doubt. An Explanatory Memorandum has been provided to assist your Lordships and I hope it has been of use.
	The measures contained in this draft order are: first, to add the "Director of National Savings" to the list of those who may be required to provide information; secondly, to redefine banks and insurers so as to take account of recent changes brought about by the Financial Services and Markets Act 2000; thirdly, to add distributors of gas and electricity to the list of information providers.
	I can quickly deal with each of those in turn. First, with regard to the Director of National Savings, it was always our intention that we should be able to obtain information about national savings products using these powers. We believed that by including "any bank" in the original list of information providers—Section 109B(2A) of the Social Security Administration Act as amended by the Social Security Fraud Act—we were also including national savings. However, while the definition of "bank"—in subsection (7) of Section 109B—embraces the National Savings Bank, it does not extend to cover other national savings products such as premium bonds, national savings certificates, pensioner bonds, deposit bonds or capital bonds. Inserting a reference to the "Director of National Savings" in the list contained in Section 109B(2A) will enable authorised officers to obtain information about the full range of national savings products in line with our original policy intention.
	Secondly, in terms of these regulations, the section on banks and insurers was also intended to be a purely technical change. We were aware at the time that the Social Security Fraud Bill was passing through its parliamentary stages, between December 2000 and May last year, that the coming into force of the Financial Services and Markets Act 2000 and the repeal of the Banking Act 1987 and the Insurance Companies Act 1982 would necessitate new definitions of "banks" and "insurers". This took place last year and the new definitions are a consequence of the coming into force of the 2000 Act. This is achieved in Article 2(b) and Article 3(a) and (b) of the draft order.
	The third push of these regulations concerns gas and electricity distributors. Over the past few months officials have been having meetings with those organisations affected by the new information gathering powers. In discussion with utility companies it has emerged that some clarification is needed. Following changes brought about by the Utilities Act 2000 there is now a clear demarcation in both the gas and electricity industries between companies who supply gas and electricity and companies who distribute these products. No one company can do both. For example, a distributor of electricity will carry electricity from the national grid to a particular property while a supplier will bill the householder for the electricity consumed.
	While the fraud Act will allow for information to be obtained from a gas or electricity supply company, powers do not yet exist to require distribution companies to provide information as to the supplier to a particular household. The draft order provides for that to take place.
	To conclude, we are making good progress in tackling fraud. Our latest figures show that in the two and a half years to March 2001 we have reduced the level of fraud and error in income support and jobseeker's allowance by 18 per cent, well ahead of the target we had expected to achieve by then. We expect this good progress to continue, but we need the tools to do the job, in particular access to information.
	I repeat that these are technical, tidying up regulations. I shall do my best to answer questions. If not, I shall write to noble Lords. I commend the draft order to the House.
	Moved, That the draft order laid before the House on 28th February be approved [22nd Report from the Joint Committee].—(Baroness Hollis of Heigham)

Lord Higgins: My Lords, as always, the noble Baroness has been helpful. We on this side of the House, like the Government, are against fraud. The noble Baroness and I spent many long hours improving the Social Security Fraud Act. It was certainly a great deal better when it went back to the Commons.
	As she rightly points out, these proposals are essentially technical in nature and cover three main areas. I was puzzled at first as to why, since it was the Social Security Fraud Act 2001, we had not taken into account the changes which took place in the Financial Services and Markets Act 2000. There is no reason why one should not proceed by regulation but I was surprised that the same sdituation existed in relation to the Utilities Act 2000 and the electricity and gas distribution companies. The blame, if there is any, for what appears to be a failure to act, lies as much on this side of the House as on the other. We certainly need to tidy up the matter now.
	With regard to banks and insurers, extension is clearly appropriate. As the noble Baroness has pointed out, this concerns a series of organisations where authorised persons—I gather about 175 of them—are able to obtain information on individuals, which may seek to confirm the firmly held belief by the department that someone is guilty of fraud. I have no points to make at all about banks.
	So far as the electricity and gas distribution companies are concerned, the noble Baroness pointed out that the change in the structure means that the distribution companies would not be available, if that is the right expression, for inquiries to be made appropriately. Again, I see no problem with that; similarly as far as the Director of National Savings is concerned. The prospect of someone engaging in fraudulent activity by investing heavily in national savings seems to me a little unlikely. I suppose so far as premium bonds are concerned, to the extent that any gains are outwith the tax system altogether, that may prevent them from falling into the clutches of the Chancellor of the Exchequer and the Inland Revenue.
	I have only two other points to make. The boundary between the Department of Social Security and the Treasury gets more and more obscure—

Baroness Hollis of Heigham: Because we no longer have a Department of Social Security.

Lord Higgins: But, my Lords, as the noble Baroness knows, it seems to me much better title than "Work and Pensions" which sounds rather sordid. Anyway, all of this refers to the Social Security Administration Act which, if the department has disappeared totally, seems a little strange, but I leave that on one side.
	I was saying that I have only two points to make. As the boundary gets more and more confused, am I right in thinking—I believe I am—that, for example, working families' tax credit is not caught by the provisions of the Social Security Fraud Act? Perhaps the noble Baroness can tell us how it is to be dealt with.
	In our debates on what became the Social Security Fraud Act we gave attention to the issue of credit rating agencies. I have become increasingly concerned about the way they operate. The noble Baroness will recall that it was agreed, rightly in my view on reflection, that the Government would not give information which it had to the credit rating agencies but would use credit rating agencies in the kind of inquiry we are discussing on the order.
	My concern, reinforced by a recent article in Which? magazine, relates to the inaccuracy of the information which credit rating agencies provide and, more particularly, the delay in ensuring they give information only on the individual about whom the inquiry is made. At the moment they are still giving information on everyone else at the same address and all the other family members.
	To the extent that both the noble Baroness and I were anxious to avoid fishing expeditions, we need to look carefully at the way in which these agencies operate and the action which is taken under the Social Security Fraud Act in making use of their services, no doubt paid for by the taxpayer.
	The noble Baroness is absolutely right. These are largely technical measures. We believe they will make the Act more effective and to that extent we support them.

Lord Addington: My Lords, I thank the Minister for her clear introduction to the order. Seeing all the regulations worried me at first. Reading through them, I discovered that it is merely a tidying up exercise and what the Minister said has certainly allayed any fears I had.
	We have one or two slight moans about basic principles. The idea of needing more tax credits may make more fraud possible overall, but that is probably not a matter best discussed at this point. I am content with the explanation given by the Minister.

Baroness Hollis of Heigham: My Lords, I am grateful to your Lordships for the response. In reply to the noble Lord, Lord Higgins, about the Financial Services and Markets Act, I am not sure that I have an entirely persuasive answer but, with the help of my noble friend on my right, reinforced by help from my left, naturally on my left, I am told,—

Lord McIntosh of Haringey: I am much more naturally on your right.

Baroness Hollis of Heigham: My Lords, I carefully did not gloss that statement when I talked about my noble friend. The Financial Services and Markets Act 2000 did not come into force until after the Social Security Fraud Act was passed. It came into force fully on 1st December 2001. That is not an explanation about the drafting but the fact that they were running coterminously was, I suspect, part of the problem.
	Obviously, tax credits are not benefits; they are credits. Therefore they do not come under the social security legislation. I realise that the noble Lord, Lord Higgins, has a different view about nomenclature here but, as a temporary member of the nomenklatura, I continue to insist that we are dealing with benefits here, not credits.
	The noble Lord talked about credit rating agencies. He is right. He will know, I am sure, that in the last 18 months or so the regulation of these bodies has passed to what was the Data Protection Commissioner, now the Information Commissioner. I find that she herself has produced leaflets on complaints about credit reference file information and what should be done about it.
	I do not know whether this is familiar to the noble Lord, Lord Higgins. She says that the most common complaints about credit reference files relate— it seems that the noble Lord, Lord Higgins, is the recipient of all the complaints in that sense—to the amount of data which appears and particularly the fact that there may be information about a person other than the applicant for credit, the accuracy of the entry and the length of time for which the record appears to continue on the file. Therefore, the noble Lord's concerns are absolutely right.
	She goes on to specify there what must be done. She has already taken some enforcement action, and she shows how people may complain about the agency and not merely correct their information. I am very happy, if the noble Lord thinks this helpful, to make sure that such a leaflet is put into the Library of the House for general information. I think it is important to draw this to people's attention. I agree that it is a very serious matter.

Lord Higgins: My Lords, I am most grateful to the noble Baroness. Yes, I have been in telephone conversation with the office of the commissioner. It has been immensely helpful. If the Government are making use of this information, they should take it with a very considerable pinch of salt. My own experience recently, not necessarily personal but otherwise, is that much of the data is very poor indeed.

Baroness Hollis of Heigham: My Lords, I accept that entirely. The noble Lord will recall our discussions during the passage of the fraud legislation. I said then that we would go to those agencies not only when we had found a discrepancy but also when we had strong grounds to believe that there was an irregularity that we wished, possibly, to clear up with the individual concerned—if he or she were the right person to give us the information. If not, we would consult other legitimate information providers. Therefore, we would only consult Experian, Equifax, or the like, in certain appropriate circumstances. That is only part of the range of materials we might need. Given the known unreliability in some cases of information received, I should be surprised if that was sufficient basis to do anything other than contribute to a jig-saw puzzle, if you like, of information.
	The noble Lord is right to give us warnings in that respect. On the basis of what he said, I shall telephone the office tomorrow to see what information is held about me. We shall see whether my experience is the same as that of the noble Lord. Given those points, I hope that noble Lords will be content to pass the order tonight and thereby allow us to proceed on our way. I commend the order to the House.

On Question, Motion agreed to.

Social Security (Contributions) (Re-rating and National Insurance Funds Payments) Order 2002

Lord McIntosh of Haringey: rose to move, That the draft order laid before the House on 6th February be approved [19th Report from the Joint Committee].

Lord McIntosh of Haringey: My Lords, with the leave of the House, it has been suggested from the Opposition Front Bench that both this and the next order on the Order Paper should be debated at the same time. I am happy to agree to that proposal, if noble Lords are similarly content. I shall speak to both orders now. When debate on the first order is concluded, I propose to move the second order formally.
	I should, first, affirm that the provisions in the first order are compatible with the European Convention on Human Rights.
	First, the order will reduce, from 11.9 to 11.8 per cent, the rate of secondary Class 1 contributions payable by all employers from April 2002 to recycle revenues arising from the introduction of the aggregates levy. It will thereby help to protect UK competitiveness.
	Secondly, for the self-employed, it raises the small earnings exception below which, depending on the level of profits, they may claim exemption from Class 2 contributions. The exception will rise next April broadly in line with prices, from £3,955 to £4,025 a year. Given that the rate of Class 2 contributions for 2002-03 will remain at £2 a week, which is a reduction in real terms, it may be that many people will choose to pay the contributions in order to protect their benefit entitlement.
	Staying with the self-employed, the draft order also sets the profits limits between which Class 4 contributions are paid. The lower limit at which contributions become due, and the upper limit, will increase broadly in line with inflation. The lower limit will rise in line with the income tax personal allowance, from £4,535 to £4,615 a year. At the other end of the scale, the upper profits limit will continue to match the upper earnings limit for employees, at £30,420 for 2002-03. This ensures that the self-employed pay Class 4 contributions on much the same range of earnings as employees liable to Class 1 contributions, and is an essential element in making the national insurance system fair for everyone.
	Thirdly, the draft order deals with the weekly rate of voluntary Class 3 contributions, which help those with insufficient contribution records in any given tax year to make up a "qualifying year" for benefit purposes. The rate of Class 3 will rise next April by 10 pence to £6.85 a week, a standard re-rating in line with prices.
	The review of contribution rates is accompanied by a report from the Government Actuary detailing the effects of the draft order, and the draft order up-rating benefits, laid by my right honourable friend the Secretary of State for Work and Pensions, on the National Insurance Fund. I am pleased to say that, for the fifth year in a row, there is no expectation that the fund will need a Treasury grant. Nevertheless, a prudent minimal provision is made in line with advice from the Government Actuary.
	As happened last year, there is a single draft order for both Great Britain and Northern Ireland. Northern Ireland has a separate national insurance scheme from Great Britain, but the two schemes are closely co-ordinated and maintain parity of contribution rates. Following the transfer of policy, Northern Ireland's social security legislation was amended to enable the draft re-rating order to include corresponding measures for the Province.
	I move now to the Tax Credits Up-rating Order 2002. Again, I confirm that the provisions in this order are compatible with the European Convention on Human Rights. The order increases the main rates and thresholds of working families' tax credit and disabled person's tax credit from 9th April this year by 1.71 per cent, in line with the increase in the Rossi index. In addition, as part of a package of more help for families with children with disabilities, it increases the disabled child tax credit and the enhanced disability tax credit for children within working families' tax credit and disabled person's tax credit by an extra £5 a week above indexation. These increases will boost the incomes of 1.3 million low income working families and disabled people who work.
	Perhaps I may explain the provisions in a little more detail. The order increases the amount of credits for an adult, child, or young person, including the extra "30 hour" tax credit that a family receives when one earner works at least 30 hours a week, and the disabled and enhanced disability credits. These credits determine the maximum working families' tax credit or maximum disabled person's tax credit that the family or disabled person may receive.
	The order also increases the income threshold for working families' tax credit and the thresholds for disabled person's tax credit. The thresholds—or "applicable amounts"—are the levels over and above which income begins to taper away the maximum award of the tax credits. The increases will provide a minimum income guarantee of £227 a week for a family with one child in receipt of working families' tax credit, £172 a week for a single person on disabled person's tax credit and £260 a week for a couple with one child on disabled person's tax credit. These figures are based on one earner in full-time work, working 35 hours a week and earning the national minimum wage.
	The order ensures that the differentials between in-work tax credits and out-of-work benefits are maintained. It provides extra help, over and above indexation, for families with children with disabilities. It reflects this Government's commitment to encourage people into work, to make work pay, and to target extra support to those who need it. I beg to move.
	Moved, That the draft order laid before the House on 6th February be approved [19th Report from the Joint Committee].—(Lord McIntosh of Haringey.)

Lord Higgins: My Lords, the House will be grateful to the Minister for his explanation of these two orders. It is helpful to take both orders together. As I said in the previous debate, a problem arises because of the extent to which the Treasury has taken over many of the former activities of what used to be called the Department of Social Security. As a result, there is now a considerable amount of overlap and confusion between the two departments.
	We have before us an order that is a Treasury order—the draft Tax Credits Up-rating Order 2002— which uprates those benefits. Noble Lords on this side of the House certainly welcome the improvement made to the disabled person's tax credit and to the position of certain children and disabled adults, and so on. Indeed, that is certainly welcome. Of course, the noble Baroness and I debated a corresponding order on 17th March—I refer to the Social Security Benefits Up-rating Order 2002—which uprated a number of other benefits.
	If we take those two lots of uprating together on, so to speak, the expenditure side, we must then consider what is happening on the income side. It seems to me that is the more interesting aspect of the matter. It is embodied in the Social Security (Contributions) (Re-rating and National Insurance Funds Payments) Order 2002, which we are debating this evening. That covers the income side, rather than the expenditure side. I leave unanswered why it is that the order should be headed "Social Security", rather than "Work and Pensions" or why it is not the Work and Pensions (Contributions) and so on Order. That is a debating point that it would be rather sordid to raise.
	There are important issues to be raised on the contributions side. Our debate on the matter on 7th March was wide-ranging, as is traditional. I do not propose to go anywhere near as wide this evening; I hope to keep within the confines of the matters raised by the order. I shall, however, make one point. There have been suggestions in the press in the past few days that the Chancellor of the Exchequer is likely to increase national insurance contributions in order to fund increased expenditure on the National Health Service. I was rather surprised by that speculation—no doubt, it is speculation—because, as I understand it, national insurance contributions are nothing to do with the NHS, although they both originate in the Beveridge concepts. Perhaps, the Minister can confirm that.
	On the contributions side, there is a report by the Government Actuary's Department. I find myself being increasingly suspicious of actuaries, particularly with regard to that report. We are told that it is based on the same assumptions as were made by the Chancellor in his pre-Budget statement, and it is apparent from the report that, as a result of the increases in benefits, to which I have already referred and which are partially covered by the other order, benefits will increase in the current year by £1,730 million. On the other hand, the re-rating order reduces the amount of revenue by £317 million in some areas and by £242 million in social security contributions. That is a total of £559 million. Expenditure has gone up by £1,730 million, and the contributions are going down by £559 million.
	In a well worn phrase, the Minister described the fund as being at a reasonably prudent level. In fact, it is not. The actuary says that a reasonable working balance would be one sixth of annual expenditure. One sixth is a singularly inconvenient fraction if one wants to convert something into percentages. If we do convert them, we see that the balance for this year is, in fact, 52 per cent of benefit payments. The Minister says, "Oh well, it's a reasonably prudent balance at the moment", when the actuary regards it as one sixth and, in fact, it is over 50 per cent. That suggests that the balance is too high. Perhaps, the Minister might reasonably have recommended, had he been an actuary for a company pension scheme, that there should be a contributions holiday, preferably not for the Treasury but for those who contribute. I should declare my interest as chairman of a company pension scheme.
	We seem to be accumulating more and more in the fund; so much that the Government Actuary's estimates are considerably out, when compared with what he said last year. The increase in the fund this year was, as he says in the report, substantial. He estimated that it would go up by £2.5 billion; it has gone up by nearly £5 billion. Not only is the balance, which is said to be prudent, way over what the actuary regards as prudent, but it has increased over the past year by nearly £5 billion. We are entitled to some explanation of why the contributions are being changed as they are, if that is the situation.
	I have one or two other questions for the Minister about the Government Actuary's figures, on which the orders are based. On page 7 of the report, the actuary refers to an item that relates to what I have just said. The balance at the beginning of 2001-02 was £19,399 million, but, for 2002-03, it is £24,192 million. That confirms what I said.
	Of particular interest are the questions raised in the Government Actuary's report and reflected in the orders about the state second pension. In paragraph 9 of page 5, the actuary says that the state second pension is, of course, about to come in in place of SERPS. The report says:
	"The new accrual regime for the State Second Pension, which was introduced by the Child Support, Pensions and Social Security Act 2000, will come into force in April 2002. Earnings-related pension will accrue at 40% of earnings".
	I shall not burden the House with the detail of what is said. However, the fact is that those accruals will go into the fund as such, without any distinction. The Government's declared intention is to switch from a situation in which 40 per cent of pensions are covered by the private sector and 60 per cent by the Government to the reverse situation. Perhaps, the time has come for the Government seriously to consider whether there is not a strong case for segregating the contributions that will be put into the state second pension, so that they are an identifiable fund.
	There has been a mass of publicity in the past few days relating to the auditor's report and the rebates that are mentioned in it, suggesting that people ought to go back from a company system into the state second pension—or SERPS, at the moment. It is highly undesirable to have people switching back and forth between the state second pension and company pensions. It is because of the way in which the Government act in reaction to the Government Actuary's report that we find ourselves from year to year being unclear about whether the rebates are sufficient to push people in or out of the state second pension. A degree of stability would be desirable, as would a move to greater funding.
	Those are my main points. I shall briefly ride my usual hobby horse. The whole of the Government Actuary's report is concerned with receipts and payments, not with the overall balance sheet of the fund. That still does not exist. I repeat my plea, which the Minister will have heard on several occasions, that it is high time that the Government Actuary was asked to estimate the liabilities of the fund. At the moment we have no clear idea of that. Given his previous commercial experience, I am sure that the Minister will agree that an operation which concerns itself only with receipts, payments and cash-flow and not with the balance sheet does not a give a clear indication to shareholders or, in this case, to taxpayers, of what is the actual underlying situation.
	Having said that, although I have expressed some doubts with regard to the re-rating order, I certainly welcome the improvements in benefits on the other one.

Lord Addington: My Lords, the emphasis of my remarks will turn more to the second of the two orders, on which I have more distinct views. When it comes to national insurance orders, I always regard them as those addressing the tax that, in effect "dare not speak its name". When we change the figures, it is always important to bear very much in mind the general taxation position.
	I am glad to say that we welcome the uprating of benefits. However, I have one query to put to the Minister about the general thinking behind the uprating. As a Treasury-based calculation, does it pay enough attention to general poverty rates and issues related to that?
	Having made those few comments, we find nothing basically objectionable in the orders.

Lord McIntosh of Haringey: My Lords, I am grateful to both noble Lords for their reception of these two orders. I shall try to respond to the points that have been made.
	The noble Lord, Lord Higgins, began by referring to speculation over recent days with regard to the rates and upper limits of national insurance contributions. Within a week of the Budget, the noble Lord will not expect me to make any comment on matters which are properly for the Budget, but he will be aware that ever since the election we have been consistent in our approach to these matters.
	The noble Lord asked me a very interesting question about national insurance contributions and the National Health Service. It is a historical fact that part of the receipts from national insurance contributions goes to the National Health Service allocation. That figure this year is £7.3 billion. A comparable figure goes to the National Insurance Fund. I do not know how far back through the sands of time that division goes, but I rather like it as a concept. Indeed, I feel a little sentimental about it, just as I feel sentimental about the term "social security", which of course was originally Beveridge's phrase, but was changed to "national insurance" by post-war governments.

Lord Higgins: My Lords, can the noble Lord say whether any of the money raised under the re-rating order before the House goes to the National Health Service? Does it appear at all in the Government Actuary's accounts?

Lord McIntosh of Haringey: My Lords, it is more complicated than that. A different proportion of each of the amounts goes to the National Health Service according to contribution rates. Again, I believe that there are historical rather than rational reasons for that, and thus there is no single figure. However, I have said that, broadly speaking, some £7 billion will go to the National Health Service allocation while, I think, a comparable figure will go into the National Insurance Fund. But it cannot be tied down to any particular contribution.
	The noble Lord asked me about the balance on the National Insurance Fund and quoted from the report of the Government Actuary. Of course the figure of one-sixth of expenditure to which the Government Actuary refers is a minimum figure. The fact that the figure, at £24 billion—which the noble Lord, Lord Higgins, is quite correct to point out is substantially larger than that fraction—is the result of the fact that the balance on the fund is the difference between two very large figures indeed. Even what seems like the large figure of £24 billion is not such a large figure as all that. This is the fifth year that we have seen an increase in the balance of the fund. The point I wish to make here is that what we do about income and expenditure from the fund has to be consistent over a period of years.
	If we were to over-react to a particular surplus in one year by allowing, as suggested by the noble Lord, Lord Higgins, a benefits or a tax holiday, that would be extremely dangerous. I do not believe that any government of the noble Lord's persuasion would want to do that either. We should remember that in 1993-94 there had to be a very substantial Treasury grant, which at that point in the economic cycle was not particularly appropriate.
	The noble Lord also asked me about the state second pension and the case for an identifiable fund for it. He made the point that switching between the two schemes is undesirable. To an extent, I think that we have to admit that switching in and out of the state second pension, or in and out of its predecessor, SERPS, is to some extent inevitable if we have a situation such as that which pertains at the moment; that is, where the number of final salary schemes is reducing. If we see a much longer trend of people changing jobs a number of times during their working life and thus making final salary schemes less attractive, then clearly there will be more switching in and out. What we are much more concerned about is to ensure that, wherever it comes from, people should be making adequate provision for their pensions. The fact that those pensions might be made up from more than one source is not necessarily a bad thing.
	The noble Lord's final question concerned the estimate of the liabilities of the fund. We are now just about within a week of moving over to resource accounting and the almost complete abandonment of cash accounting in the public accounts as the main measure. The point made by the noble Lord about having a balance sheet as well as an income and expenditure account is, to my mind, well made. It is one which I think should be brought up and deserves parliamentary time as we move towards the new method of public accounting.
	Turning to the second order, I was asked by the noble Lord, Lord Addington, whether we were using the correct index from the point of view of poverty. The point about using the Rossi index, which is RPI with certain housing costs excluded from it is, first, that it has been used for this purpose since 1983. There are advantages in consistency. Secondly, it maintains the differential between in-work and out-of-work provisions, as I hope I made clear when introducing the order. Different measures are used for different benefits and purposes in government.
	Again, some of those measurements exist for historical reasons rather than for reasons which we could now rationally justify. For example, the fact that sometimes we take prospective RPI and sometimes past RPI is difficult to justify rationally, except on the basis of using a swing from one measure to another for base party political purposes. We are not doing that here.

On Question, Motion agreed to.

Tax Credits Up-rating Order 2002

Lord McIntosh of Haringey: My Lords, I beg to move.
	Moved, That the draft order laid before the House on 14th February be approved [20th Report from the Joint Committee].—(Lord McIntosh of Haringey.)

On Question, Motion agreed to.

Lord McIntosh of Haringey: My Lords, I beg to move that the House do now adjourn during pleasure until 8.37 p.m.

Moved accordingly, and, on Question, Motion agreed to.
	[The Sitting was suspended from 8.20 to 8.37 p.m.]

National Health Service Reform and Health Care Professions Bill

House again in Committee.
	Clause 11 [Duty of quality]:

Baroness Northover: moved Amendment No. 93:
	Page 17, line 29, after "quality)" insert—
	"( ) in subsection (1), after "of" there is inserted "the Department of Health"; and"

Baroness Northover: This amendment was first proposed by my honourable friend Dr Evan Harris in another place. It seeks to include the Department of Health itself in the inspection process.
	The purpose of the amendment is simple. The danger is that CHI will spend its time inspecting the work of hospital and primary care trusts; but the trusts are simply doing what the department is asking of them.
	Obviously, the Government must set priorities in the NHS. That is what they are elected to do, and they will be called to account at election time. But quite how their policy towards the health service is implemented depends a great deal on how the department itself operates.
	If, as the Government claim, they do indeed manage to de-centralise, and also—as we seek—more proposals are brought directly to Parliament for approval, or if the NHS is put at arm's length from government, the role of the department might not be so critical. However, that is not the case—and will not be the case even if this Bill as drafted completes its passage. Therefore, the amendment explores the idea that it is also of key importance to patient care to see whether the actions of the Department of Health are also in the best interests of patients.
	The Audit Commission has a remit over the Department of Health in terms of how resources are spent. So, for example, the Audit Commission has commented adversely on resources used to reduce waiting lists when these did not greatly assist in patient care. It was also argued by the Minister in the other place that CHI could comment on the commissioning procedure. But that is at a stage down the track from the Department of Health.
	We in Parliament clearly have a key role to play in bringing the Government to account for actions within the Department of Health. But if it is indeed appropriate for the Audit Commission to assess whether the department is spending its resources wisely, then surely it is also worth considering having expert assessment of whether the Department of Health, in its priorities and procedures for running the health service, is actually acting at all times in the best interests of the patients.
	It is often difficult to gain access to that information as parliamentarians. I point to a report in today's Guardian on the Commons Science and Technology Committee, investigating what is happening to resources for cancer. I have raised this matter previously, and sought Written Answers from the Minister last September. My question was: precisely what happens to money earmarked for cancer since so little of it seems to be reaching its intended target—this despite a government fanfare on the matter. The Guardian article quotes Gordon McVie, of Cancer Research UK, as wondering whether the money,
	"has been absorbed like creosote into the fence post of the administration of the health service".
	Quite so.
	The Science and Technology Committee reports the difficulty of getting any information on this matter out of the Department of Health. Clinicians on the ground dare say little, lest they offend against all the rules barring them from commenting. Surely there is a case for an inspection body having the right and the duty to go into the Department of Health to make its own investigations and recommendations. It might well say that the department had failed in the way that it had dispatched the money to protect it from marauding administrators trying to fill black holes. Or it could conclude that ring-fencing, when there were so many desperate needs in the health service, was inappropriate. Either way, its expert investigation and report would help to inform both parliamentarians—and indeed the electorate—who are supposed to be able to bring the Government to account.
	I do not expect that the Minister will consider the amendment to be a very good idea; nor may those advising him. But while we seek ever more transparent and effective scrutiny procedures in the rest of the NHS, and of those working in the health professions, surely the Minister must also give consideration to such scrutiny closer to home. I beg to move.

Earl Howe: I add my support to the amendment. I completely endorse everything that the noble Baroness has said. The odd thing about Section 18 of the Health Act 1999 is the narrowness of its compass. The duty of quality created in that section falls on health authorities, PCTs and NHS trusts. It is expressed as a duty,
	"to put and keep in place arrangements for the purpose of monitoring and improving the quality of health care which it provides to individuals".
	That section is one of the most important in the Act, yet something big appears to be missing from it. Like the noble Baroness, I am struck by the absence of any duty on the Department of Health or the NHS as a whole to promote quality in healthcare.
	The Minister's reply is likely to be that the department as such does not deliver healthcare services. There are two rejoinders to that. One is that, while it may not deliver services at the front line, it is instrumental in providing those services—which is the term used in Section 18. I am thinking in particular of the public health role of the CMO. When we debated public health earlier this week, the Minister made it clear that the CMO was ultimately accountable within the body of the NHS for the effective delivery of the Government's public health policy. It seems strange that only lower down the NHS chain of command should a duty of quality be laid down. I might have expected a government amendment to this Bill creating a duty of quality on the NHS as a whole, including the Department of Health, accompanied by a power for the Secretary of State to devolve or delegate that duty to NHS bodies at the front line.
	If the Department of Health has been exempted from the duty of quality because it does not commission healthcare services, the same could be said of strategic health authorities, but I take it that they, as successor bodies to health authorities, will be subject to the duty. Perhaps the Minister could clarify that point.
	The second rejoinder to what I suspect the Minister will say is to point to the multitude of powers that will continue to reside with the Secretary of State, notwithstanding the devolutionist flavour of the Bill. Those powers include an ability to intervene directly in the affairs of PCTs, the power to impose targets on the health service, the power to dispense or withhold money according to how well or badly those targets have been met and so on. If there is no duty of quality on the Department of Health, as I read it the centre can legally direct PCTs and trusts in a manner that need take no account of the duty of quality, yet expect PCTs and trusts nevertheless to adhere to that duty. An obvious example springs to mind—the waiting list initiative. If such an initiative obliges PCTs and trusts to override clinical priorities so that those waiting longest, and not necessarily the sickest patients, are treated first, it is very difficult to see how PCTs and trusts can claim, while fulfilling that directive, to be improving the quality of healthcare that they provide.
	The noble Baroness has pinpointed an interesting and potentially far-reaching anomaly in the Bill and in the 1999 Act. It will be illuminating to hear what the Minister has to say.

Lord Hunt of Kings Heath: I have been rather surprised by the suggestion that quality is not at the forefront of all the department's thinking in its strategic leadership for the health service. That is why we have set up so many of the bodies that the noble Baroness, Lady Noakes, referred to earlier, such as the National Patient Safety Agency and the Commission for Health Improvement and various other mechanisms. One of the Government's key aims, through the department, has been to improve the overall quality, safety and standard of services to the public.
	Section 18 of the 1999 Act came up with the duty of quality to rectify an anomaly that had existed in the NHS for far too long. Although there were financial duties on NHS organisations, before 1999 Act there was no statutory duty on the NHS relating to the quality of the patient care that it provided. That is but one action that we have taken to improve quality generally in the health service. The department has set and implemented an integrated programme of measures to monitor and improve the quality of the healthcare provided by the NHS, as set out in A First Class Service in 1998, strengthened in the NHS Plan in 2000 and taken further still through the recent listening exercise involving patients and the public in healthcare. It is why we also established the quality taskforce in the department, under the co-chairmanship of the Chief Medical Officer and the Chief Nursing Officer. Quality permeates all the department's thinking and policy development. The noble Earl, Lord Howe, has debated waiting lists with me on a number of occasions. He will know that we have made it abundantly clear to the health service that, in meeting waiting list targets, clinical priorities must always come first.
	On the duty of quality and the issues that the noble Baroness has raised, surely we need to go back to Section 1 of the 1977 Act, which in large part replicates the original 1946 Act, setting out the key aim of the health service. It states:
	"It is the Secretary of State's duty to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—
	a) in the physical and mental health of the people of those countries, and
	b) in the prevention, diagnosis and treatment of illness,
	and for that purpose to provide or secure the effective provision of services in accordance with this Act".
	I emphasise the words "designed to secure improvement in". That is a broad description of what we are seeking to do, which entails within it issues to do with quality and everything else that is important to the development of the National Health Service.
	As for Amendment No. 93, the risk seems to be that it would get in the way of the Department of Health's accountability, via Ministers, to Parliament on all aspects of securing healthcare for those who need it. My experience of the past three years is that Department of Health Ministers are very accountable to Parliament. When I think of the number of Parliamentary Questions answered daily, the number of debates in your Lordships' House, the vigour of the Select Committee hearings that I have attended, I am absolutely certain that Parliament has endless opportunities to hold Ministers to account and for Ministers to come to both Houses to explain their own performance.
	Although of course I accept that parliamentary scrutiny of a publicly funded NHS is crucially important, I do not believe that the amendment as proposed would help that. I think that, in some ways, it would detract from ministerial accountability to Parliament. Surely our parliamentary democracy must rest on that direct line of accountability.

Baroness Northover: I thank the Minister for that reply, and the noble Earl, Lord Howe, for his very detailed support. The Minister's comments seemed to bear out some of what I was saying. He referred to the original 1946 Act and also to the 1977 Act, and yet, in the 1999 Act, it was felt necessary, despite that previous legislation, to establish a duty of quality. As the noble Earl pointed out, it is very striking that it includes health authorities, primary care trusts and so on, but does not include the Department of Health, which established the duty. It seems a trifle odd that the department should not be included.

Lord Hunt of Kings Heath: The department's overriding responsibility was enshrined in the 1946 Act and confirmed in the 1977 Act. The duty of quality was established for NHS organisations because, as experience has shown, discussions in the boards of NHS organisations revolved primarily around management, finance and human resource issues but only very rarely touched on quality issues. Consequently, the specific duty of quality was introduced. In its reviews of clinical governance, CHI has focused particularly on the degree to which the boards of those NHS organisations have addressed clinical governance and quality issues. That is why NHS organisations were dealt with in that way.

Baroness Northover: I thank the Minister for that comment. I should be very interested to see the agendas within the Department of Health, but I do not suppose that they are available. I also wonder whether they include items contributing to the quality debate.

Lord Hunt of Kings Heath: I assure the noble Baroness that quality and patient safety issues are paramount in the many discussions held on the fourth floor of Richmond House. As I said, the Chief Nursing Officer and the Chief Medical Officer—who are very powerful individuals with very distinguished records on quality and safety—are leading our quality programmes. I can therefore assure the noble Baroness that quality is a full part of all our considerations in developing policy and managing performance in the NHS.

Baroness Northover: I thank the Minister for that reply. I would not in any way wish to detract from what has been done in trying to introduce a duty of quality in other parts of the health service. If anything, as I said, I should like that duty to be extended. I shall read what the Minister had to say. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Northover: moved Amendment No. 94:
	Page 17, line 31, at end insert "including the provision of accessible information for patients, and monitoring the provisions of health and safety legislation and infection control measures"

Baroness Northover: This amendment seeks to ensure the provision of accessible information to patients and also the monitoring of health and safety legislation and infection control measures. All those elements are important to the quality of patient care. We should perhaps have dealt with them in separate amendments, but, if we had, it would have made the night even longer.
	Clearly it is vitally important that information is accessible not only to parliamentarians but to patients. As we shall undoubtedly hear when we discuss patient complaints, things often go wrong because information is not available. Not only should patients be physically well treated, but their more general welfare should be addressed. Access to information is a part of that.
	Health and safety regulations relate particularly to staff, and it is essential that they are properly addressed and assessed. The BMA has concluded, however, that, despite existing legislation and guidance, health and safety are still not universally guaranteed throughout the NHS. The NHS has a responsibility under the Health and Safety at Work etc. Act 1974, and various other regulations on the management of health and safety, to ensure the safety of all employees, contractors, and members of the public as patients and visitors. Each NHS trust and primary care trust has a statutory duty to provide an environment that is safe,
	"as far as is reasonably practicable",
	to use "the best practical means" to achieve its objectives, and to use
	"the best available technology not entailing excessive cost".
	I am rather concerned by those provisos.
	As part of its inspection process, CHI would be in a prime position to observe whether premises, equipment, practices and procedures in each trust are sufficient to enable best clinical practice. It seems reasonable, therefore, that the Bill should be amended to ensure that that function is covered by CHI.
	Although infection has—as Nightingale made clear—always been an issue, it has become a key one in recent years. However, post-antibiotics, there was certainly an optimism that infection was well and truly under control. That optimism has long since passed. Problems such as new variant CJD have introduced areas of concern. It is clearly essential that infection control is properly monitored. One issue which arose in dealing with the problem of disposable instruments, once it became evident that instruments could be a means of infection, was that many hospitals simply did not know which instruments had been used on whom. However, some did know. Clearly, one of CHI's functions should be to spread and encourage best practice. I beg to move.

Earl Howe: I am delighted, once again, to support the noble Baroness, Lady Northover, in this amendment. In reading Subsection 4 of Section 18 of the 1999 Act—again we are hampered by not having the wording fully in front of us—I cannot help thinking that much hinges on the meaning of the word "services". Healthcare is defined in that subsection as,
	"services for or in connection with the prevention, diagnosis or treatment of illness".
	The noble Baroness seeks to add to that definition,
	"the provision of accessible information for patients".
	I should have thought that, on a strict legal interpretation, that was a service, and that that part of the amendment is therefore unnecessary. If the emphasis is on the word "accessible", again, I should have thought that accessibility was bound up with the notion of quality. However, having uttered that caveat, I have much sympathy with the suggestion that those words should be included. It is not so very long ago that patients were expected to accept the treatment they were offered by doctors and be grateful for it. The idea of informing patients about the treatment they were receiving or might receive or about services that they could access was considered somewhat eccentric. So, despite any strict legal interpretations, I am in favour of making this provision explicit, if only as a means of recognising that we are trying to move away from paternalist medicine.
	The next part of the amendment has an even stronger claim to our attention. Monitoring the provisions of health and safety legislation and infection control measures does not seem to me to be a service. However, it is an integral part of being a good employer, as the noble Baroness pointed out, and providing public health services in the broadest sense. As we were informed by the Minister on Monday, much of the monitoring function in the public health context will rest with the PCTs. My only faint worry here is that if we pursue the amendment to its logical end there would be a duty on PCTs and trusts to make arrangements to monitor the quality of monitoring. It is perhaps for discussion what we might understand that to mean.
	While the duty of quality already extends to monitoring the quality of healthcare, the noble Baroness made a good point in drawing our attention to health and safety requirements—which surely do not constitute healthcare—and measures which might be in place to deliver the public health agenda, which again need not in all cases fall under the heading of healthcare.

Baroness Masham of Ilton: I support the amendment and, in so doing, ask the Minister who will be in overall charge of infectious control and send out the guidelines to our hospital trusts? With the increase of tuberculosis, it must be a health and safety issue to nurse someone in an open ward. I am sure that the Minister knows of the case of the young girl a few weeks ago who was diagnosed with pneumonia. She had tuberculosis; she was sent home and died. This is an important issue. Such infectious diseases are on the increase.
	Can the Minister tell us the position regarding matrons? We were promised matrons. I believe that someone has been appointed in Birmingham. Matrons have much to do with cleanliness, which concerns the importance of the amendment.

Lord Clement-Jones: I rise briefly to strongly support the amendment tabled by my noble friend Lady Northover. I do so firstly because of my connection with Cancer Bacup, which has a strong ethos of provision of information to cancer patients, not only by telephone, which is accessible, but through written printed information available in hospitals. It is important that hospitals ensure that such information is available. That seems to me to be a key function to allay some of the fears cancer patients have about the treatments they are undergoing. My second reason is to point out a number of issues which the Improving Lives coalition has brought to my attention in relation to those who are visually impaired.
	There is a clear link between how well health services meet disabled people's requirement for accessible information and the quality of care offered to such groups. Indeed, failing to provide accessible test results or to ensure that patients have timely and accessible information about appointments or information leaflets about their condition can have a potentially devastating impact on the health of visually impaired patients and their ability to manage their own health effectively. It is their belief that the performance of the health service in that area is wholly inadequate. The existing duties under the Disability Discrimination Act to provide information about services in an accessible format do not appear to be biting.
	A number of surveys have been carried out. One in 1997 by the RNIB demonstrated that less than half of the health authorities which answered the questionnaire had guidelines for meeting the health information needs of blind and partially-sighted people. An RNIB survey of over 200 visually impaired eye clinic patients found that six in seven people attending ophthalmic patients' outpatients' departments receive their appointment letter only in normal-size print. One in four people had to get someone else to read their appointment letter for them.
	The latest research by the RNIB on accessible information should provide a severe jolt to all health service policy makers and practitioners. It found that more than one in five of the total adult population struggle to read labels and instructions on medicines or letters from their doctor. That rises to two in five of those who are 75 or over and to three in four people with sight problems.
	The consequences of inaccessible health information can be severe. There are a number of cases of mixing up medication; taking the wrong drugs and missed appointments. Sometimes, patients are in the position of undergoing procedures or operations without accessible information explaining what will happen to them. On the other hand, the provision of accessible health information has been shown to result in more effective and appropriate use of health services, reduced stress, improved recovery of illness and operations and increased compliance with medication and treatment.
	I believe that the case for the visually impaired is particularly strong. The health service is not responding adequately to their needs. It should not be left to charities to be responsible for monitoring provision in this area. We should not place the onus on individual disabled people to continually complain and threaten legal action under the DDA. For those reasons, I strongly support the amendment.

Lord Filkin: I agree with the objectives of most of those who have spoken on the amendment. However, I believe we have adequate statutory provisions in place to address them.
	The department strongly recognises the importance of provision of accessible information for patients. The noble Earl, Lord Howe, put it clearly: moving away from a paternalistic service which doled out what professionals thought was appropriate to a much more informed dialogue with patients so that they understand what is happening and are able to participate in that process. That clearly is the goal of the health service to which we are strongly committed. We have taken steps to ensure that NHS bodies make such information widely available. We do not for one second imply that we are where we want to be in terms of fully realising that.
	On health and safety, we also recognise the importance of the NHS having in place both arrangements for, first, monitoring the provision of health and safety legislation and, secondly, measures for infection control. Enforcement of the provisions of health and safety legislation which are statutory requirements, is already carried out by the Health and Safety Executive in relation to the NHS. CHI is working to develop a memorandum of understanding with the Health and Safety Executive to further co-operation between the two bodies.
	On infection control, the NHS Plan implementation programme makes it clear that hospitals must have effective systems in place to prevent and control hospital acquired infections. This is a core requirement underpinning the targets in the NHS Plan and the department has already taken a number of actions to ensure that these systems are in place. The national standards for hospital acquired infection (controls assurance standard) was revised in December 2001.
	Hospital infection control guidelines were published in January 2000 and community infection control guidelines are currently under development. The first two quarters' data of the mandatory surveillance of MRSA were published for the department by the Public Health Laboratory Service in February this year as part of the development of a comprehensive National Health Service surveillance service.
	The control of healthcare associated infections was recently highlighted in the Chief Medical Officer's strategy for combating infectious diseases, Getting Ahead of the Curve, and an action plan is currently being developed. The noble Baroness, Lady Masham, asked who is in overall charge of infection issues. Clearly the Department of Health has the overall responsibility. On the distressing case of a nurse with TB in an open ward, the chief executive of every board in that situation is responsible to his board for achieving the appropriate quality and preventing infection in such circumstances.
	The noble Baroness also raised the important issue of what is happening with modern matrons. A considerable number of them are in post. They are highly relevant to the issue of cleanliness and infection control, as the noble Baroness made clear, and there are positive signs that they are having a good effect. The Department of Health also conducts spot checks on cleanliness, which we believe are necessary.
	Turning to monitoring and the improvement of infection more generally, Section 18 of the Health Act 1999 places a duty on those National Health Service organisations providing healthcare to individuals to put and keep in place arrangements for the purpose of monitoring and improving the quality of that healthcare.
	The extension of the definition of "healthcare" in Section 18, by Clause 11, means that there will be a general duty on National Health Service bodies, pursuant to Section 18, to monitor and improve the quality of the patient environment. That implies a duty to have regard to the availability of information to patients. I concur with the noble Earl, Lord Howe, that services undoubtedly have to incorporate not just the provision of a technical product or service but the totality of the patient relationship that encompasses the dialogue of requests for information and understanding. One cannot deliver good services for any sector without that sort of relationship being in place. By reason of the extension of the definition, CHI will also clearly be able to comment on these matters in its reports, although enforcement of the health and safety legislation will be a matter for the Health and Safety Executive.
	The noble Lord, Lord Clement-Jones, raised the extremely important issue of visual impairment. That is an example of the sort of issue on which we would expect and hope patient forums to focus. They would look at the quality of service provision, not just to the public generally but to those who need access to a different form of service from the standard service that is good enough for the vast majority. Those who are visually impaired are four-square within that definition. We very much hope that the patient forums will attend to those issues.
	NHS Direct also has some relevance. It is by no means a total panacea, but it clearly helps those who are visually impaired to have access to high quality information and advice. As the Committee knows, the progress so far is not perfect, but the service is extremely highly valued by many members of the public. We want to take it further and make it better, which is of enormous relevance to the visually impaired.
	Patient surveys are being undertaken in every acute trust, and we expect them to pick up on some of those issues of whether the particular disadvantages suffered by some people are being adequately met by the current services. As the clause already refers to the environment in which services are delivered in general terms, which includes having regard to the provision of information and any hazards or risks of infection, I suggest that the amendment to Clause 11 is not necessary and should be rejected.
	The issue is not one of having more statutory definition, which is in place, but having the persistence, resolution and drive from the department, together with the commitment of managers, to make some of those goals that already have statutory effect commonplace and universal throughout the service.

Baroness Northover: I thank the Minister for that sympathetic reply. I also thank other Members of the Committee who have participated in the debate.
	Clearly more needs to be done to make information accessible. I am encouraged by the Minister about the direction in which the Government are heading. It also sounds encouraging that CHI will be doing more regarding health and safety.
	One of my concerns about infection control is that there are various other bodies looking at the issue. With these new structures there is a danger that things may become fragmented. I hope very much that the Minister is right that with persistence and resolution the Government will move these matters forward. I shall read in Hansard what the Minister has said. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	Clause 11 agreed to.

Baroness Northover: moved Amendment No. 95:
	After Clause 11, insert the following new clause—
	"INDEPENDENT HOSPITALS
	The Secretary of State shall by regulations extend the functions of the Commission for Health Improvement set out in section 20 of the 1999 Act (functions of the commission) to any independent hospital as defined by section 2 of the Care Standards Act 2000 (c. 14) (independent hospitals etc.)."

Baroness Northover: Amendment No. 95 seeks to include private hospitals in the same inspection system as the NHS. I declare an indirect interest as my husband, as well as being an NHS surgeon, is also in private practice at the London Clinic and the King Edward VII hospital.
	I was astonished when I first discovered that private hospitals were not inspected in the same way as NHS hospitals. That is quite wrong. The case for bringing private acute care within the same inspection system as that for the NHS has long been argued by my noble friend Lord Clement-Jones. I should not be surprised if Members of the Committee thought that they would hear from him on this amendment. The noble Earl, Lord Howe, has also argued this case and the Chamber has approved the proposal. So this issue may be quite familiar to many noble Lords today.
	From these Benches we welcomed CHI when it was set up in the Health Act 1999. However, we felt strongly that patients should receive the same high quality care wherever they were treated. Therefore, we felt that it was appropriate for CHI to inspect acute care in private as well as NHS hospitals.
	In the Care Standards Bill 2000 we welcomed the regulation and inspection of social care, and private and voluntary healthcare premises. But we argued again that acute care in private hospitals should be inspected to the same level as in NHS hospitals.
	Patients really do deserve the best possible protection, whether they are being treated in the NHS or the private sector. I noted earlier with great interest that the Minister, in relation to medical registration and training, stated that there should be the same entry requirements wherever a doctor intended to practise, whether private or NHS. The same principle should apply here.
	The Commission for Health Improvement covers independent institutions where NHS patients are treated and private care within NHS hospitals, but not private care within private hospitals. We were concerned that neither of the earlier Bills gave the assurance that a duty of quality identical or similar to that required for the NHS was required for the independent sector. But it is only when things go wrong that people discover that that is so. When one thinks of some of the cases that have come up in recent years, it is clear that those being treated in the private sector thought that they were buying not simply a nice hotel room with its own telephone and TV but the consultant of their choice, backed up by an institution with the highest possible standards.
	Many institutions have such high standards, but it remains highly inappropriate for them to be inspected as though they were nursing homes. There are over 200 hospitals in the private sector which comprise approximately 10,000 beds. There are some 800,000 treatments carried out by 17,000 doctors, most of whom also work in the NHS.
	As I have mentioned, in the relevant health Bills in 1999 and 2000, noble Lords supported the proposal that independent hospitals should be brought within the scope of the regulations. In the end the point had to be conceded in the face of government opposition in the other place.
	We believe that every patient deserves common minimum standards of care. The Government have a responsibility to ensure that minimum standards are maintained and seen to be maintained. We need consistency in those standards and consistency in enforcement.
	The Government have argued in the past that the two healthcare systems under which NHS and private hospitals operate are different; that one is a managed system and the other is a regulated system. But inspection is to do with regulation. It must be right that the Government take appropriate measures to protect their citizens within the private sector and for that sector to come within the thorough inspection system that we have now come to expect, and welcome, within the NHS.
	In January, Mr Milburn's response to the Kennedy report was that there would be a coming together and better co-ordination of NHS inspection systems; and that the CHI is to be strengthened and made more independent. Now is surely the time, if not before, to ensure that the private acute sector is properly brought within the same kind of inspection system as that which applies to the acute sector of the NHS. I beg to move.

Baroness Noakes: We fully support the intent of the amendment—as with the earlier amendment about merging the function of the National Care Standards Commission and the CHI. In Committee on 18th March, the Minister mentioned, in respect of the Care Standards Act 2000,
	"bringing Section 9 into force".—[Official Report, 18/03/2002; col. 1203.]
	I understand that that would bring the inspection of independent sector hospitals within the remit of the CHI. What precise effect would that have—and to what extent would it meet the excellent points made by the noble Baroness?

Baroness Masham of Ilton: I, too, support the amendment. Patients can be at risk in a private hospital when they are in single rooms. In an NHS hospital, other patients are around. When a person gets into difficulty and there are no staff around—which often happens when there is a shortage, as there is now—patients help each other. My husband has been treated in NHS hospitals and in a private hospital. In the latter, he got a thrombosis in his leg and was discharged without a proper check-up, which could have been avoided. I feel strongly that minimum standards should apply in all hospitals.

Lord Hunt of Kings Heath: I have great sympathy with the broad thrust of the noble Baroness's arguments but it is a question of timing. The amendment is rather premature, in view of the amount of work that must be undertaken to take forward the rationalisation of inspection agencies at national level to which my right honourable friend the Secretary of State referred following the Bristol inquiry report.
	We made provision in the Care Standards Act 2000 for the CHI to exercise functions of the National Care Standards Commission in relation to the independent sector. The noble Baroness kindly reminded me of the debates on that subject. She will recall that, when we enacted the Bill, we considered it right that the regulation of private health care should be different from the arrangements for the independent review of NHS bodies by the CHI.
	Life moves on and there have been considerable developments since we debated that point. The Bill gives the CHI a new function of inspection against published standards. That responsibility will extend to services for NHS patients wherever they are treated, including those provided by the independent sector. It is clear from Government action in the past few months that an increasing number of NHS patients are being treated in the independent sector. It is clear also that—particularly during the transitional period, as we try to build capacity in the NHS—we will continue to use the independent sector. While we are clear that private and voluntary health care must remain under a system of regulation or licensing, the time is right for the CHI to inspect independent hospitals on behalf of the National Care Standards Commission.
	The noble Baroness, Lady Noakes, reminded me that I made it clear on Monday night that we will bring Section 9 of the 2000 Act into force shortly and make regulations, so that the CHI may exercise the commission's function of inspection in relation to indpendent hospitals.
	The noble Baroness, Lady Noakes, asked me to fill in some of the detail. Of course, we are still considering that and it will be contained in the regulations. However, essentially, the regulation of private healthcare institutions remains the responsibility of the National Care Standards Commission. We propose that the inspection function itself should be undertaken by the Commission for Health Improvement, but acting within the ambit of legislation that gives the overall responsibility to the National Care Standards Commission. It is a halfway house, as it were. We are trying to get as much consistency as possible in the inspections process, bearing in mind that the current legislative requirement is for the National Care Standards Commission to have the ultimate responsibility for private hospital regulation.
	I said that that is a transitional phase because, as my right honourable friend the Secretary of State made clear, we are seriously considering have to obtain closer working and, over time, organisational integration between CHI, the Social Services Inspectorate, the National Care Standards Commission and the Audit Commission so that health and social care services are subject to common standards, whether they are provided by public, private or voluntary sector organisations.
	That is clearly an extensive piece of work to be undertaken during the next few months. That is why it would be premature to legislate in the Bill to bring together CHI and the National Care Standards Commission. As I said, we are bringing Section 9 into operation as a means of having as much consistency as possible between CHI and the National Care Standards Commission. I hope that I have made clear our intended direction of travel. Although I do not recommend that we accept the amendments, I hope that the noble Baroness will accept that we are going in the same direction, but that a considerable amount of work will need to be done.

Lord Clement-Jones: That is about as close to an apology for previous legislation that I have ever heard a Minister give. If the Minister wants to achieve such integration, will not further primary legislation be necessary?

Lord Hunt of Kings Heath: I was simply seeking to suggest to the noble Lord that, since our debates a couple of years ago, life has moved on and there have been developments. The relationship of the National Health Service with the independent sector has evolved. For that reason, it is right to reconsider the issues.
	I accept that primary legislation will be required at the end of the journey to integrate national inspection systems against common standards. It would be premature to legislate in the Bill, because much work needs to be undertaken.

Lord Clement-Jones: I have one further question. Will that be before the National Care Standards Commission is even formed and up and running?

Lord Hunt of Kings Heath: That is because we generously allowed such a long lead time to allow the commission to establish its work.

Baroness Northover: I thank the Minister for his reply. We shall obviously share many more late nights here in future. I also thank the noble Baronesses, Lady Noakes, and Lady Masham of Ilton, for their support. I am intrigued and encouraged and shall have to read what the Minister said. To know that he is sympathetic to the amendment is obviously extremely nice. However, he says that it is premature to legislate at this point. Given that we are so busy setting up primary care trusts with all their duties, it strikes me as strange that the amendments should be regarded as premature while we rush ahead in other areas.

Lord Hunt of Kings Heath: In his speech my right honourable friend did not confine himself to the National Care Standards Commission and the Commission for Health Improvement. He also referred specifically to the Audit Commission and the Social Services Inspectorate. The speech followed up our response to the Bristol inquiry.
	These are complicated matters that need full consideration. Even if we wanted to wave a magic wand and say, "Yes, we'd love to legislate in this Bill", it would not be possible to bring forward carefully thought-out legislation at this stage.

Baroness Northover: It strikes me as ironic that it is fine to change the structure of the NHS fairly rapidly, which is a complicated thing to do, but in this area, where the lives of individual patients are affected, it is said to be premature to take action on the proper inspection of hospitals. That surprises me.

Lord Hunt of Kings Heath: The proposals in the Bill arise from the NHS Plan and Shifting the Balance of Power. They have been given careful thought and consideration by the Government over a considerable period of time. My right honourable friend's speech only a few weeks ago arose directly from the recommendations of Professor Sir Ian Kennedy in the Bristol inquiry, which reported only a few months ago. That is why it is important that we have time to reflect on the best way to achieve integration between these different bodies.

Baroness Northover: I thank the Minister for that reply. However, I point out that in this Chamber, which may not be the fastest-moving place, a decision was taken in 1999 and 2000 to include private hospitals in the inspection system. It is a shame that it is taking a while.
	I am encouraged by the Minister's comments. I hope that when the inspection is extended—it certainly sounds as if it will be—it will cover the whole of the private acute sector and not simply those parts in which the NHS is involved. It is important for citizens as a whole—for all patients—to know that they are safe in the institutions in which they are treated. I look forward to reading the Minister's comments in Hansard. On that basis, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	Clause 12 [Further functions of the Commission for Health Improvement]:

Baroness Noakes: moved Amendment No. 96:
	Page 18, line 11, at end insert—
	"( ) In subsection (2), at the end of paragraph (b) there is inserted "including co-ordinating visits to general practitioners, Primary Care Trusts or to NHS trusts with other bodies carrying out monitoring or inspections of those premises"."

Baroness Noakes: The amendment seeks to amend Section 20(2) of the Health Act 1999, which deals with the functions of the Commission for Health Improvement. The amendment would allow the regulations made under that subsection to include CHI taking into account the co-ordination of CHI's own visits with those of other bodies carrying out monitoring or inspecting the same premises. Trusts, GP surgeries and so on face a multitude of visits and inspections from various bodies in addition to CHI. There are visits by the Audit Commission, the Royal Colleges, CHCs and, if the Bill is passed, patient forums, and many other bodies, such as the Modernisation Agency.
	My noble friend Lord Peyton of Yeovil told us on the second Committee day that the multiplicity of inspections was described to him as,
	"death by a thousand visits".—[Official Report, 18/3/02; col. 1203.]
	The British Medical Association feels strongly about the issue and supports the amendment. I hope that the Minister will say whether the Government intend to do anything to streamline the visits and relieve the burden on doctors, other health professionals and their staff.
	The bottom line is that every minute spent on such visits is a minute not spent on patient care, and anything that can be done to minimise their impact will be welcomed. The amendment does not seek to cure the totality of the problem but seeks to co-ordinate visits which are focused on monitoring and inspection. It is a modest contribution to the problem and I hope that it will commend itself to the Minister. I beg to move.

Baroness Northover: I support this amendment. We all agree that CHI is a welcome creation doing a good job. However, given the duplication—no doubt other Members of the Committee will have a copy of the chart from the BMA of the various ways in which doctors can be assessed, monitored, checked, revalidated and so forth—the complexity is obvious. We should do all we can to ensure that that duplication and that kind of complexity is made simpler.
	Most of the visits made by those bodies are of course appropriate. But we can try to ensure that there is co-ordination and that inspections by the various organisations do not cause disruption. An interesting analogy was drawn in the other place where they talked of the digging up and re-digging up of roads. If we can simply co-ordinate the various bodies who have to dig up the roads, it would make more sense than endlessly having one digging up a road this week and another digging it up next week. On the basis therefore that we seek co-ordination of this kind of inspection, I support the amendment.

Lord Hunt of Kings Heath: From my remarks on our intent to rationalise the inspection mechanism at national level, Members of the Committee will understand that I am sympathetic with the broad arguments of the noble Baroness in terms of a rationalisation of inspectorates at local level.
	I make two points. First, the reason why various organisations visit the NHS is to ensure that quality and safety—issues we have already debated—are paramount. One makes no apologies for the extension of those inspection agencies into primary care. However, I fully accept that there must be co-ordination and rationalisation, and that the burden put on busy people operating front-line services is as light as is possible consistent with a rigorous approach to safety and quality.
	The Commission for Health Improvement is at the moment piloting its inspections of primary care trusts. Part of those inspections will involve visits to some individual GP surgeries. In the discussions that the department had with CHI we came to a mutual understanding that those visits will be light touch, for the very reason the noble Baroness put forward.
	The CHI has also taken other steps to co-ordinate activity with relevant bodies. It has already agreed a draft statement of principles for consultation covering how it plans to improve co-ordination with the Audit Commission, including external audit, NHS internal audit, the Health and Safety Executive and the NHS Litigation Authority, including the clinical negligence scheme for trusts. CHI also has a memorandum of understanding with a number of relevant bodies including the commission, the Audit Commission, the Health Service Ombudsman, the General Medical Council, the UKCC, the National Clinical Assessment Authority and it is working to develop others, including the Health and Safety Executive. My understanding is that copies of those memoranda have already been placed in the Library.
	Therefore the Commission for Health Improvement is well exercised of the need to ensure that there is co-ordination and to avoid duplication. We will encourage the commission to continue that good work, which is entirely consistent with what we seek to do at national level. We do not need the amendment as it is tabled. The Secretary of State already has the powers to encourage CHI to continue this process of co-ordination and I am satisfied, from my meetings with CHI, that it is fully cognisant of the need to move in the direction the noble Baroness suggested.

Baroness Noakes: I thank the Minister for that. Would he just say how long CHI has been trying to co-ordinate its visits? I ask this because the complaints about the duplication of visits, the multiplicity of visits, and the serial visits, are of relatively recent origin. The source of this amendment was not some long-forgotten complaint; rather it relates to current complaints, in particular by the British Medical Association. Even if CHI has been doing it for some time, it has not been doing it very well; and that makes one think that perhaps an amendment is needed.

Lord Hunt of Kings Heath: The Commission for Health Improvement has not been in existence for very long, so it is not surprising that there is, inevitably, a learning curve. One expects CHI to learn from some of the concerns that have been expressed. In recent discussions with officials in the department, I have discussed the particular issue of the piloting of the clinical governance reviews of primary care trusts where the issue of light-touch visits to GP surgeries has been raised. I am satisfied that CHI is fully cognisant of the need to try to rationalise these as much as possible.
	The process is developing. It takes time to gain experience and for the inspection agencies to learn from that. I believe that learning is taking place. Noble Lords' comments tonight will certainly feed back to CHI and I think they will be very helpful.

Baroness Noakes: I thank the noble Lord for that, and I thank the noble Baroness, Lady Northover, for her support for this amendment. I am not convinced that the words actually match up with actions on the ground, but I am sure that those who have been particularly concerned about this matter will look carefully at the Minister's words in Hansard, as indeed shall I. In the mean time, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Northover: moved Amendment No. 97:
	Page 18, line 12, after "(2)", insert—
	"(a) paragraphs (a) and (b) are omitted, and"

Baroness Northover: Amendment No. 97 seeks to delete two paragraphs of the Health Act 1999 in relation to powers held by the Secretary of State in regard to CHI.
	As Professor Kennedy has said, it is essential that CHI,
	"should be suitably structured so as to give it the necessary independence and authority",
	to carry out its work. The paragraphs that we seek to delete from Section 20 of the 1999 Act are ones which allow the Secretary of State by regulation to make provision,
	"as to the times at which, the cases in which, the manner in which, the persons in relation to which or the matters with respect to which any functions of the Commission are to be exercised ... [and] as to the matters to be considered or taken into account in connection with the exercise of any functions of the Commission".
	The Government say that they are making CHI more independent. If so, how does this fit with these lines? They give the Secretary of State power to restrict the ability of CHI to talk to the people to whom it needs to talk, to make investigations and reviews when it wants, and to consider cases as it wants. Nothing, and certainly not a Secretary of State, should threaten the remit, independence, scope and ability of CHI to make such investigations.
	When my honourable friend Dr Evan Harris introduced this amendment in the other place, the Minister there argued that removing these provisions cut across the Secretary of State's ability to co-ordinate inspection. However, they do not look to me like a series of powers which ensure co-ordination and, drawn as widely as they are, there has to be a risk that they could be used to undermine the independence of CHI. I therefore flag up this amendment as indicative of the kind of area which must be addressed if CHI is to be, and to be seen to be, independent of the Secretary of State and not controlled by him. I beg to move.

Baroness Noakes: I rise to speak briefly in support of this amendment. To some extent it anticipates a later amendment dealing with the independence of CHI, and we fully support that direction of travel. Indeed, one might say, looking at Section 20 of the 1999 Act, that this amendment singles out paragraphs (a) and (b) but one might even extend it further and look at the whole of Section 20 to discover why a Secretary of State should keep any of the powers to direct CHI in such a detailed way if it is decided to give CHI more independence.
	I do not know whether the Minister is going to say that the powers need to be kept in reserve and would be used only in exceptional cases. If he does say that, I think that we have to take it with a pinch of salt because the mere fact of the existence of such powers, whether or not they are used in a formal sense, subtly undermines the independence of such bodies. If a body knows that the Secretary of State can issue directions or make regulations telling it what to do, the mere existence of that power tends to induce compliance and reduce independence. We support the amendment.

Lord Hunt of Kings Heath: I should state clearly to the Committee that we are very keen to enhance the independence of the Commission for Health Improvement. There is no reason for the Government to wish to inhibit that independence. The whole rigour of what we are seeking to achieve—namely, to drive up standards in the health service—depends to a great extent on the credibility of the commission and on the way it is regarded by both the public and those working in the health service.
	There simply would not be any reason for the Government to wish to undermine the independence of the Commission for Health Improvement. When we debate Clause 14, Members of the Committee will discover that we are making moves to remove the requirement, for example, for the Secretary of State to consent to the appointment of CHI's chief executive, and the Secretary of State's direction-making power in respect of the terms under which the commission employs people. That is why we are providing for certain of CHI's functions in relation to the collection and analysis of data and performance assessment to be carried out by the Office for Information on Healthcare Performance.
	At the same time, the performance ratings that we published last year will, this July, be jointly produced by the department and CHI. In July 2003, the performance ratings will be produced by the commission. We are most anxious that CHI should perform as rigorous a role as possible. There is no question of seeking to interfere in the inspection process that CHI undertakes. We have discussions with the commission about its workload because, from the department's point of view, we have been encouraging CHI to undertake as many inspections as is possible.
	Regular meetings take place between the chair and the chief executive of CHI to enable us to engage in mutual discussion about its work and the issues that have arisen. The department's Ministers are most concerned to learn from CHI what it has discovered in the health service. I particularly commend the CHI reports that comment on how much clinical governance, for example, is ingrained within the work of boards, and, indeed, whether boards have information strategies. Many other issues are identified in CHI reports, and that information can then help the department in its performance management of the NHS.
	I turn to the purpose of the amendment. It seems to me that the noble Baroness, Lady Noakes, sought to forecast what I would say in response. She is absolutely right in that respect. Ultimately, the Secretary of State is accountable to Parliament for the performance of the Commission for Health Improvement. In the very unlikely event that any serious problem should arise in the way that CHI performed its functions, or in its general operation, the Secretary of State must have a power of intervention. That is why the power is in the Bill. It is no different from many other non-departmental public bodies.
	I can assure the Committee that that is why the power is there; it is not there to intervene and to dictate to CHI what should be mentioned in its reports. The power forms a necessary part of Ministers' accountability to Parliament. For that reason, I urge the noble Baroness not to press the amendment.

Baroness Northover: I thank the Minister for his reply, and the noble Baroness, Lady Noakes, for her support. I reiterate that we welcome CHI; indeed, we very much welcome the developments that have come in its wake. However, we should consider what might happen as we come up to an election, for example, or consider the case of the Chief Inspector of Prisons. For a while, an inspector's reports may be welcomed, but, later, he may be out in the cold. The first inspections may be considered useful, but if there are repeated poor reports on hospitals, as we approach a general election, the temptation for a Secretary of State who has some direct control over an institution such as CHI will be intense.

Lord Hunt of Kings Heath: There are two safeguards against that. First, there is the integrity of the chairperson, chief executive and non-executive directors of the Commission for Health Improvement. Anyone who knows Dame Deirdre Hine, the chair of CHI, or Dr Peter Homa, the chief executive, would quickly come to the view that they are people of great integrity who would not bow to any influence of that kind.
	Secondly, if powers of direction had to be issued, that would be in the public domain. I should have thought that that would create a much bigger noise than any adverse report by CHI on an NHS trust. CHI has already produced a considerable number of reports. Some are outstanding reports on hospitals. For instance, CHI produced a report on Addenbrooke's NHS Trust three or four weeks ago, which indicated that the hospital was outstanding in many ways. The reports on other hospitals have been disappointing and negative and have identified areas in which improvement must take place.
	The purpose of setting up CHI was to have a rigorous, independent process that indicated to the public and to the NHS that we had a system that really got to grips with problems in the health service. It is inconceivable that Ministers would wish to interfere with that process.

Baroness Northover: I thank the Minister for those comments. The Government certainly deserve credit for setting up CHI, given that no previous government did so. I am happy to give the Government that credit.
	However, if we consider the model of the Chief Inspector of Prisons, we can see what may happen down the track. The Government might be relieved to see the amendments proposed by the noble Baroness, Lady Finlay of Llandaff, which really would remove CHI from the control of the Secretary of State and make it answerable to a Select Committee of Parliament. If it were directly answerable to Parliament, there would be no temptation for the Secretary of State to exercise—or otherwise—any influence over CHI, should pressures arise down the track. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Noakes: moved Amendment No. 98:
	Page 18, line 15, leave out subsection (5).

Baroness Noakes: Amendment No. 98 is a probing amendment. It would remove subsection (5) of Clause 12.
	At first sight, the clause is innocuous, simply requiring the Audit Commission to consult the Commission for Health Improvement on its programme of value for money studies in relation to the NHS. However, the Audit Commission is a fully independent body with statutory duties to carry out audit. In arriving at its programme, it consults many people and organisations, as one would expect a responsible public body to do. I hope that few would argue with the proposition that the Audit Commission is an effective and responsible public body.
	Why do the Government feel that it is necessary for statute to prescribe whom the Audit Commission should consult? Do the Government feel that the Audit Commission is not doing its job properly? Will the Minister say what the Government's view is? Why is the Audit Commission treated differently from the National Audit Office? The National Audit Office is not required by statute to consult over its audit programme.
	Such clauses raise concerns about other agendas. We know from the Government's response to the Bristol report, which has been quoted several times during our deliberations in Committee, that the Secretary of State does have an agenda with regard to the relationship between the Audit Commission and CHI, because he said that there needed to be closer working and, over time, organisational integration between CHI and, inter alia, the Audit Commission. That raises very serious issues about the integrity of public sector audit.
	I ask the Minister to explain what are the Government's precise intentions in relation to the Audit Commission. I ask him also to say what is meant by "closer working" and when "organisational integration" might take place. Can he confirm that no changes are intended which would undermine the independence and effectiveness of the public audit function in relation to the NHS? I beg to move.

Lord Hunt of Kings Heath: The question of the intention of my right honourable friend since his speech concerning the integration of inspection functions has been made clear in my response to the amendment moved a short while ago by the noble Baroness, Lady Northover. I said then that I thought her amendment was premature because the detailed work that will have to be done to develop ideas about future integration has only just started. That is because the Bristol report is not old and we have had to consider our comments on the work programme that needs to follow. In a sense, therefore, I do not think that I can answer the questions raised by the noble Baroness because this is work in hand and we shall need to consider these matters very carefully.
	However, I can say to the noble Baroness that of course I greatly respect the work of the Audit Commission. I have had long experience of dealing with the commission and reading its reports. I know of the benefits that it has brought. Equally, as noble Lords themselves have pointed out, and just as the noble Baroness argued earlier, I believe that we need to sort out inspections at local level and national level. We need to avoid duplication. The whole purpose of including the clause in the Bill was not in any way an attempt to restrict the independence or decision-making process of the Audit Commission, but rather merely to ensure that consideration would be made of CHI's work programme so that the organisations themselves could best consider how to avoid duplication and hold general discussions about their respective work programmes.
	I should stress that there is no suggestion whatever that in doing this we are seeking to undermine the independence of the Audit Commission, which I agree is an extremely important facet of its work.

Lord Clement-Jones: Perhaps I may pick up on a point just made by the Minister. I welcome what he has said about the Audit Commission because I am sure that he is aware that considerable value is put on the commission's value-for-money audits as a specific exercise, quite apart from any health aspect. It has that specialism. I believe that strong opposition would be brought to bear on any attempt to try to over-integrate in that respect.

Lord Hunt of Kings Heath: One thing that I have learned over the years is that the Audit Commission is a very powerful defender of its own interests. I am sure that in any discussions about its future role, it will be well able to put across its own point of view.
	I should also have said to the noble Baroness, Lady Noakes, that I understand that in the relevant section of the Audit Commission Act 1998, we are adding to the names of the Secretary of State for Health and the Comptroller and Auditor-General in relation to the National Audit Office. Given the importance of the Commission for Health Improvement in relation to inspections in the health service, I should have thought that it was appropriate to add CHI's name to that list.

Baroness Noakes: I thank the Minister for that reply. I do not feel very much the wiser for it because I still do not quite understand why this particular consultation requirement needs to be put on to the face of the Bill. However, often when we urge the Minister to accept amendments which seek to make things clear, we receive a response which states in effect that of course the Government already do that and so it is irrelevant to put anything on to the face of the Bill. Here we are trying to take something off the face of the Bill in circumstances where a responsible Audit Commission would almost certainly consult, and yet we have the argument put back to us in a different way.
	I am very surprised that the Secretary of State could have said what he did on 17th January in relation to the organisational integration between CHI and the Audit Commission, and yet here we are, two months later, and the Minister can give the Committee no details whatever. I find that surprising. I want to reflect further before Report stage. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Finlay of Llandaff: moved Amendment No. 98A:
	Page 18, line 17, at end insert—
	"(6) The Commission for Health Improvement shall present annually its report to the health joint select committee."

Baroness Finlay of Llandaff: In moving Amendment No. 98A, I shall speak also to Amendment No. 114A. I should make it clear that I shall not be speaking to the other amendments in the group. They will be addressed in due order later in the Marshalled List.

Lord Hunt of Kings Heath: It may help the Committee if I make it clear that the other amendments have been degrouped and that we are speaking only to Amendments Nos. 98A and 114A.

Baroness Finlay of Llandaff: I thank the Minister for that. I am grateful to the noble Baroness, Lady Northover, for having set the scene for the amendment. The Minister referred to the report, Learning from Bristol. That report states:
	"The NHS is quintessentially a statement of political values. Thus, it is inevitable and right that central government should seek to lay down the parameters of the NHS's activities, particularly in the realm of finance and priorities. But, once this is done, the systems for monitoring the extent to which it is meeting its stated aims must, in our view, be de-politicised, so as thereby to rekindle and maintain public confidence in the NHS".
	It is this role that I wish to address.
	I am grateful to the Minister for expanding on some of the increased freedom that CHI will experience. I understand that it will be able to appoint chief executives through the commission itself and that its reports are to be laid before Parliament. The Bill will enable CHI to undertake inspections, including where NHS services are provided from premises not directly owned by the NHS. The Minister has clearly outlined the need for CHI to be independent.
	All the regulatory bodies concerned with the NHS—which is a national service—must be answerable directly to Parliament. Other regulatory bodies—the professions' regulatory bodies—will be discussed in detail later.
	I am suggesting that a parliamentary committee should be drawn from both Houses, ensuring representation from the four countries of the United Kingdom, and that such a committee shall never have a majority of members from one political party. In the event of a coalition of two parties, it would be important to ensure that it did not operate in such a way as to create a majority on the committee. Thus the committee would be politically neutral in terms of pressure prior to an election. It is anticipated that representatives of the government of the day would not constitute more than 40 per cent of the proposed health Joint Select Committee.
	Such details are suggestions only at this stage; it is the principle that is of concern. Currently, there is no professional regulatory body for managers. May I preface my next remarks by stating that I work for an NHS trust with excellent management, which maintains an open dialogue with all staff at all grades. However, our recent debate involving research and teaching highlights the need for resources such as rooms, photocopying and IT facilities.
	The CHI reports have been excellent. Like the Kennedy report, they have outlined that the state of the NHS is in the hands of managers, and good management is integral to clinical governance. I sincerely hope that the recommendations of the Kennedy report will be followed and that such regulatory bodies will be directly answerable to Parliament.
	CHI inspects the service and recommends improvements. It must be free to exercise its functions with rigour. CHI must report to Parliament in such a way that it can be questioned—it should not simply lay a report before Parliament—and hence the idea of the committee.
	Amendment No. 114A seeks to ensure that the organisation referred to in the Bill as the "patients forum", which will have an important function in obtaining the views of NHS users, will also be answerable in such a way. The patients forum must seek the views of NHS users—be they patients, relatives or carers—and it must be allowed to be independent of service providers. I believe that it should have equal standing with the inspection roles of other inspection bodies. Therefore, it should be able to present its report to such a parliamentary committee. While the patients forums will be working with trusts, they must have the ability to be completely independent of the trusts, and of the government of the day.
	Fortunately, the consultation processes that have taken place in Wales, which were outlined earlier in our debates, have been very effective in some areas. We are fortunate to have retained community health councils. I know that we are not to debate community health councils, but the report from such patients forums must have the high status and standing that we have been able to retain in community health councils in Wales. They have recently been involved in two important research projects—one with the Organ Retention Advisory Group, where they sought the views of the general public, and another where they have been working on the standards that patients and their relatives require from the health services in Wales. I beg to move.

Baroness Northover: I welcome the amendment. The Select Committees of the Houses of Parliament have already developed an important scrutiny role. They should in future develop that function further, acting on behalf of Parliament, and be able to specialise in particular areas and report to Parliament.
	If CHI answered to a Select Committee such as that suggested in the amendment, the Minister would not need to worry about needing to protest that no undue control or influence is exerted over what all agree should be an independent body. Therefore, I strongly welcome this proposal.

Lord Hunt of Kings Heath: This has been an interesting debate about the accountability to Parliament of CHI and of the patients forums, on which we shall no doubt have an interesting discussion in some four weeks' time.
	The amendments proposed by the noble Baroness, Lady Finlay, seek to assume that Parliament would decide to create what is referred to as a health Joint Select Committee. Later, we shall debate also the group of amendments dealing with the council for the regulation of health care professionals in relation to this committee. What in effect the amendments would do would be to have the Commission for Health Improvement and patients forums present their annual reports to the Joint Select Committee.
	The current position is that CHI makes an annual report on the exercise of its functions to the Secretary of State, like other non-departmental public bodies. But it is an important measure of its great independence that, under Clause 14(4), CHI will also in future be required to complete an annual report on the quality of services to NHS patients, which the Secretary of State will be under a duty to lay before Parliament. So, even if Parliament decided to set up a Joint Select Committee as proposed in the amendment, it would not add anything if CHI were to send its report there as well as to Parliament.
	Equally, patients forums will make an annual report to the Commission for Patient and Public Involvement in Health, as well as to the Secretary of State. These reports will feed in to the commission's own annual report, which the Secretary of State will be under a duty to lay before Parliament.
	I understand what the noble Baroness is getting at. However, we are in an extremely difficult position if we seek in the Bill to suggest how Parliament might establish Select Committees in the future. That is not the way in which Parliament operates, and it is not the way in which decisions are made about the agreement to set up Select Committees of either House or Joint Select Committees.
	Of course, if Parliament decided to establish such a Select Committee, it would be the duty of NHS bodies to co-operate with it. That is what happens at the moment. For example, the Select Committee on Health is currently undertaking an inquiry into the work of the National Institute for Clinical Excellence. I spent two and a half happy hours before the committee a week or so ago undergoing what might be described as effective scrutiny. There is nothing to prevent Parliament holding organisations such as the Commission for Health Improvement to account through its normal processes. Our aim in the Bill is to enhance the reporting of those organisations to Parliament. For that reason, while I certainly understand what the noble Baroness is getting at, I urge her to consider not pressing the amendments.

Baroness Finlay of Llandaff: I am most grateful to the Minister for his reply and for his generosity in understanding what I am getting at, as I am a novice to the parliamentary system. I am grateful for his explanation. I shall consider the issues further and may return to them later. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	Clause 12 agreed to.

Baroness Noakes: moved Amendment No. 99:
	After Clause 12, insert the following new clause—
	"PUBLIC HEALTH FUNCTIONS OF THE COMMISSION FOR HEALTH IMPROVEMENT
	The Commission for Health Improvement shall have such further functions as may be prescribed relating to the management, co-ordination, provision or quality of public health services for which prescribed NHS bodies, service providers, local authorities or other bodies have responsibility."

Baroness Noakes: The amendment would extend the remit of the Commission for Health Improvement to public health. It would enable the Secretary of State to prescribe functions relating to the management, co-ordination, provision or quality of public health services, for which a wide range of bodies have responsibility.
	CHI's functions under the Health Act 1999 are expressed in terms of healthcare, as are the amendments in the Bill. Notable by its absence from CHI's remit is public health, yet public health issues are as important as—some would say more important than—those involved in the delivery of healthcare.
	The Committee has already debated the importance of public health in relation to the roles of the strategic health authorities, primary care trusts and regional directors of public health. It is fair to say that our debates on earlier amendments left a number of concerns hanging relating to whether those public health responsibilities would in practice be discharged effectively.
	We know that the Government's intention is that PCTs will take the lead on health issues and that they will have a director of public health. We know that they will be encouraged to work in public health networks and that the directors of public health will come new to their responsibilities in PCTs from a variety of backgrounds, some medical and some non-medical.
	It seems inevitable that the public health function of PCTs will need some strong oversight. CHI seems the obvious organisation to provide that. However, the amendment is not just about keeping an eye on PCTs and their new public health functions. We know that there are major public health issues to be grappled with. The amendment would give CHI, as an independent inspectorate, the responsibility for finding out what is being done on various public health issues to achieve public health aims, as well as disseminating best practice and reporting when not enough is being done.
	I hope that the Minister will accept the amendment as one based on plain common sense. If he resists it, will he explain why public health must remain outside CHI's remit and what alternative arrangements would give the same oversight and rigour? I beg to move.

Baroness Northover: I support the amendment. Several key issues are emerging as this Bill rolls along. Noble Lords are giving a guarded welcome to the notion of devolving resources and decision-making in the NHS, but there is enormous concern about the speed with which that is happening and whether PCTs are anywhere near being ready to take up their key tasks. There is increasing concern about matters that particularly require a national overview. Public health is one such matter.
	Public health—like teaching and research, as we debated the other day—is too often likely to be squeezed out by what seem to be more pressing concerns. Devolution is one thing, but fragmentation is quite another. What we are hearing about the parcelling out of public health responsibilities to one lead official here and one there obviously causes concern; it is not a recipe for satisfactory co-ordination. Moreover, as has emerged too clearly from the Bristol inquiry, too little data are available in the health service to know what is happening where, and to know what has been happening where. The fact that public health is a key responsibility therefore has to be built into PCTs' remit.
	Even then, however, the way in which PCTs exercise that responsibility will have to be carefully scrutinised. I fully agree with the noble Baroness, Lady Noakes, that that is where CHI may be able to assist. That is why it is being proposed that CHI's role should be extended to cover the monitoring, inspection, reporting, co-ordination, management and quality of public health. I therefore very much welcome the amendment.

Baroness Finlay of Llandaff: In supporting this amendment, I shall approach it from a slightly different angle: public health's importance, as we have discussed, to national defence. I know that Ministers have recently received many questions on smallpox vaccine. In the event of a sudden catastrophic epidemic of any sort, the public health services will be called on to be the plank on which catastrophic infections are controlled. The public health services co-ordinate, for example, the control of meningitis outbreaks.
	The organisation of public health services is absolutely crucial in their ability to respond. I support the amendment because the organisation of such services must be in good order at all times so that they are not found wanting when called on in an emergency.

Baroness Masham of Ilton: Public health covers so many important aspects. There is a strong feeling that PCTs will be overloaded, but everyone working in the National Health Service and social care should be helping with public health. I am sure that the Commission for Health Improvement can help improve public health as it goes about its work. It can look, encourage and report if not enough is being done. I hope that the Government will support the amendment.

Lord Hunt of Kings Heath: I agree that this is a very important matter, although, as the Committee will know, I am more optimistic than some noble Lords about the capability of primary care trusts to accept the very important public health role they are being given. The term "public health services" goes very wide and might include protection against communicable diseases or other hazards to health and health promotion. The ambit of the expression is not entirely clear because the term is not currently defined in the Health Act 1999.
	Noble Lords will recall that on 10th January the Chief Medical Officer announced proposals for a health protection agency to streamline the services involved in the prevention and control of infectious diseases. This agency will provide an integrated approach to all aspects of health protection, including chemical and radiological hazards as well as infectious disease control. The agency will take over functions currently performed by the Public Health Laboratory Service, the National Radiological Protection Board, the Centre for Applied Microbiology and Research, and the National Focus for Chemical Incidents. It will also assume responsibility for employing consultants in communicable disease control.
	The new agency will work closely with regional and local services and the expert government advisory committees. It will also work with CHI where there are serious deficiencies in standards of infection control in hospitals, primary care or other health service premises. That will give us a great deal of confidence about the national arrangements and the integration of public health protection surveillance services, as well as infectious disease control, about which I know that noble Lords are anxious.
	Alongside that we shall have robust performance management of the public health function throughout the National Health Service. From this April the regional directors of public health will design, develop and maintain public health networks. They will be responsible for the overall tackling of the root causes of ill-health inequalities through the health component across government policies. They will manage and co-ordinate the health protection and emergency planning functions in their regions. The focus of the directors of health and social care performance management function will be to take a national overview of performance, negotiating performance agreements with strategic health authorities, holding strategic health authorities to account for performance and supporting the development of individual organisations and the whole system to help them to deliver improvements to patients.
	While not duplicating the work of directors of public health in primary care trusts or that of regional directors of public health, strategic health authorities will also have responsibility for performance management of public health action within primary care trusts and in hospital trusts. In future, we shall have a strong performance management system with clear performance management relationships coming down from the regional directors of public health, reporting to the directors of health and social care and to the Chief Medical Officer. That provides an effective way of ensuring that the public health function is properly integrated, managed and monitored.
	However, I accept that the noble Baroness raised important issues in favour of giving recognition to the importance of public health service in the way that she suggested. I readily acknowledge that there are complex issues in terms of clarifying the range of public health services that might appropriately be brought within CHI's remit, the relationship between the bodies responsible for those services and those currently responsible for their inspection and regulation. I have already mentioned the creation of the new national agency.
	The view that the Government take is that there are a number of important matters which need to be worked through over the next few months. While I cannot support the amendment tabled by the noble Baroness, I can assure the Committee that the Government are giving serious consideration to how the issues can best be taken forward and to the extent that CHI's remit needs to be revisited in these areas. I shall keep noble Lords fully informed on those matters.

Baroness Noakes: I thank the Minister for that response. Indeed, I thank the noble Baronesses, Lady Northover, Lady Finlay and Lady Masham, for their contributions to the debate. I was encouraged at the end of the Minister's comments that this was being kept under review by the Government. It might seem churlish of me to say that what I heard before that perhaps was not so encouraging as it seemed to resist the notion of an independent inspectorate reporting in the successful mode that the noble Lord described earlier today in relation to its other responsibilities. We were trying to take that success and the ability to penetrate to other real issues and to spread that across.
	It is not right to pursue the matter today. We shall think further on it in the light of what the Minister said about the Government's future action. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	Clauses 13 and 14 agreed to.

Baroness Noakes: moved Amendment No. 100:
	After Clause 14, insert the following new clause—
	"PATIENT CHOICE
	It shall be the duty of the Secretary of State in carrying out his functions under the 1977 Act to ensure that so far as it is reasonable for him to do so, persons who receive services under the 1977 Act are given a choice as to the time, manner and location of those services."

Baroness Noakes: The amendment would insert a new clause after Clause 14 and would place a duty on the Secretary of State to ensure that people receiving services in the National Health Service are given a choice as to time, manner and location of those services.
	I shall quote from a recent speech, which states:
	"The balance of power has to shift decisively in favour of the patient ... Patients throughout the National Health Service, helped by their referring GP, will be able to make informed choices about how they are treated, when they are treated and by whom they are treated".
	That could easily have been said by my honourable friend Dr Liam Fox, and it could also easily have been an extract from Working with Patients—the White Paper which heralded the National Health Service reforms of more than a decade ago. But no, it is an extract from a speech made by the Secretary of State for Health in January this year.
	Only a few days ago, the Department of Health issued a document entitled, Extending Choice for Patients, which deals only with the rather modest extension of choice to long waiters for heart surgery; but it is a move in the right direction and we welcome it.
	Several noble Lords remarked on Second Reading and elsewhere that the Government's policies have moved on in several respects since they introduced the Bill. We think that it is unsatisfactory that when the Bill has completed its passage the National Health Service will still not have a definitive statutory framework representing current government policy. It is not satisfactory for the Government to announce a series of changes that are not reflected in the Bill.
	I am sure that the Minister is aware that we have reservations about many of the Government's policies towards the National Health Service, but we think that this issue of patient choice is one thing that the Secretary of State has started to get right. We agree with it and we want to support him in his new conversion to our ideas by seeing a positive duty to achieve patient choice in the National Health Service legislation.
	The Secretary of State said that patient choice would be achieved within four years and I do not believe that that is inconsistent with the wording of the new clause, which refers to,
	"so far as it is reasonable for him to do so".
	If the Government would prefer a more definite commencement period, I am sure that the new clause could be amended to that effect. I hope that the Government will welcome the amendment. I beg to move.

Lord Hunt of Kings Heath: I warm to the habit of the noble Baroness, Lady Noakes, of referring to speeches made by my right honourable friend. I am glad that she finds them so interesting.
	The question of patient choice is extremely important. Any vision of a modern National Health Service would need to involve patient choice. The noble Baroness, Lady Northover, referred earlier to information that helps patients to make informed choices. We all agree with that, but I do not think that it would be appropriate to put the matter on a statutory basis. It is much more a question of policy to be decided by the Secretary of State. We have signalled that greater choice is very much a part of what we seek to do.
	By 2005 all patients will be able to choose the date, time and place of their treatment. One of the must-do targets set out in the National Health Service plan is that by the end of 2005, all patients will be able to seek treatment at a time that suits them. That is a clear and public commitment. Through the additional resources that we are making available to the National Health Service for the next year, we are demonstrating our commitment by piloting patient choice from July. At that time, patients with coronary heart disease will be able to benefit from patient choice. When a patient has been on an in-patient waiting list for coronary heart disease treatment for more than six months, he or she will be offered swifter treatment in a different National Health Service hospital, or in the private sector, or in another EU country. We are looking to extend the pilots across other specialisms and in different areas. It is important for the patients who will benefit from that pilot, but it will also be a valuable learning experience in terms of where we need to get to by 2005.
	As part of our proposals for patient choice, we have made it clear that patients should be able to choose where they are treated. Patients and their doctors will be able to consider a range of options. That might be at the local NHS hospital or at diagnostic and treatment centres or in the private sector or overseas. We want patients to be able to compare different waiting times in different hospitals and across different specialties. We want GPs and referring consultants to be able to book appointments online.
	That surely is, as I have said, the vision of a modern health service. I do not think that it is appropriate to place on the statute book in primary legislation the wording that the noble Baroness has suggested. At the end of the day it falls to government Ministers in their accountability to Parliament to decide on the National Health Service. That is what we have done. I have made it clear that patient choice is a priority. I have no doubt that we shall deliver on that. But it is very much a matter for Ministers to make those decisions and in turn to be accountable to Parliament for so doing.

Baroness Noakes: I thank the Minister for those comments. I am perplexed. I had understood him to be moving in the direction of patient choice—that is what he outlined to us—but he said that somehow having the duty of patient choice was not appropriate. I did not hear why it was not appropriate, other than it was something to do with policy decided by the Secretary of State.
	The Government show a great lack of commitment to the principle of patient choice, if that is something that the Secretary of State wishes to keep to himself and to prioritise or de-prioritise from time to time. In the light of those comments, we should rightly be sceptical of the Government's apparent conversion to patient choice. I want to think about the matter further. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Baroness Noakes: moved Amendment No. 101:
	After Clause 14, insert the following new clause—
	"Targets for patients
	(1) It shall be the duty of the Secretary of State to achieve the following targets for patients—
	(a) no patient should wait more than 48 hours for an appointment to see a general practitioner,
	(b) no patient should wait longer than thirteen weeks from the time of referral from a general practitioner for a first appointment to be seen as an out-patient,
	(c) no patient should wait longer than six months from the time that he is first seen as an out-patient for the procedure or other treatment decided upon,
	(d) no patient should wait longer than one hour after arrival at an accident and emergency unit or similar unit before being seen by a doctor or a qualified nurse practitioner, and
	(e) no patient should wait longer than four hours for admittance to a hospital from an accident and emergency or similar unit after a decision has been made that he should be admitted to a hospital.
	(2) The Secretary of State may by order define how the targets set out in subsection (1) are to be measured.
	(3) The Secretary of State may by order add to the targets set out in subsection (1) or alter those targets so that shorter times are specified.
	(4) The Secretary of State may by order set targets for shorter times than set out in subsection (1) for defined categories of patients or services.
	(5) An order made under subsections (3) and (4) shall not be made unless a draft of the order has been laid before, and approved by a resolution of, each House of Parliament."

Baroness Noakes: In moving Amendment No. 101, I shall speak also to Amendments Nos. 102 to 104.
	The amendments are important because they deal with patients' experience of the NHS throughout the times that they have to wait at various points in the system. The amendments focus on the areas of patient experience which the Government believe to be important, because they included them in the NHS Plan.
	Amendment No. 101 introduces a new clause which sets up the basic framework of targets for patients. It provides that the Secretary of State has a duty to achieve some basic waiting time targets for patients; namely, not having to wait more than 48 hours to see a GP, 13 weeks for an outpatients appointment, six months for an inpatient or other treatment, more than a hour in accident and emergency before being seen or waiting more than four hours for admittance from accident and emergency.
	Those are largely the targets which were spelt out in the NHS Plan. The plan referred to a "war on waiting". These targets in the light of our current experience of the NHS might well seem ambitious. However, if one looks to the experience of other European countries the acceptable times are much shorter than the times that we have included. So these are not perhaps very ambitious targets.
	Regardless of whether or not the targets are ambitious, it is far from clear whether those set out in the NHS Plan will be achieved. Last year the Audit Commission reported on accident and emergency performance. It noted that waiting times had got worse since 1996.
	Professor John Yates, recently writing in the Health Service Journal, noted that some of the waiting time data are showing some worrying trends. One of his conclusions was that the rate of sustained waiting time reductions needed to deliver the targets has never been achieved in the past, with the implication that the targets are likely to be missed.
	Patients need to know that these minimum standards will move from aspiration to reality. That is why the proposed clause lays the responsibility on the shoulders of the Secretary of State. It allows him to introduce additional targets and set shorter targets. It is not the Government's intention, I imagine, that the targets in the plan are desirable end states.
	Simply placing a duty on the Secretary of State to achieve a target says nothing about what should happen if he fails. Amendment No. 102 requires the Secretary of State to set up compensation arrangements. Patients want to be treated, not compensated for non-treatment—but some form of compensation, which it is left to the Secretary of State to make by order, should concentrate the minds of service deliverers and make it clear to patients that it is their right to receive treatment within certain minimum periods.
	The compensation scheme would take effect in 2004, except for the 13-week and six-month targets, which are given a date in 2003. I am sure that the Minister will say that those deadlines are tough compared with the 2005 of the NHS Plan but I doubt that dates alone will be the sticking point with these amendments.
	The Secretary of State cannot be expected personally to achieve patient targets so Amendment No. 103 allows him to delegate the duties and compensation scheme to primary care trusts, NHS trusts or strategic health authorities.
	It is no exaggeration to say that patients have been let down by the Government who have promised much but delivered little. The amendments put patients at the heart of the Government's responsibilities to the NHS. I beg to move.

Lord Hunt of Kings Heath: I am surprised that the noble Baroness should say that the Government have delivered little. I invite the Committee to consider the huge increase in capacity and in the number of medical training places; the 30,000 extra nurses working in the health service; the development of services such as NHS Direct; and the development of a new safety and quality culture. Much has been achieved and we are indebted to NHS staff for their hard work.
	I share the noble Baroness's desire to see waiting time targets achieved and we are determined that they will be. That is best done by the setting of targets and effective performance management rather than by laying down limits and targets in statute law. In the NHS those matters have always been the responsibility of Ministers to determine and that will continue—which is why the NHS Plan clearly sets out the maximum waiting time targets that we expect to be delivered.
	By the end of March this year, the maximum waiting time for a first outpatient appointment will reduce from more than six months to an absolute of six months. The maximum wait for inpatient treatment will be cut from 18 months to 15 months. Maximum waiting times will continue to fall on a staged basis each year. By 2003, the maximum wait for a first outpatient appointment will be five months; by 2004, four months; and by 2005, three months.
	Similarly, for inpatient treatment the maximum wait will be 12 months by 2003, nine months by 2004, and six months by 2005.
	Subject to other NHS Plan targets for increasing capacity, the Government's eventual aim is to reduce the maximum waiting time for all stages of treatment to three months by 2008.
	The latest figures for the end of January show that many trusts are on the way to meeting the initial targets that we set. We will continue to press the health service to do everything it can to increase its capacity and to get more doctors, more beds into use and more facilities, with increasing use of the independent sector where it can provide greater capacity. All those efforts are being made by the health service to deliver on the waiting time targets.
	The question arises of whether it is appropriate to put a compensation scheme for patients on the face on the Bill. I do not believe that that is the appropriate way forward. It would be wholly a departure in the enactment of health service legislation. I note that when the Conservative Party developed the Patient's Charter, it never proposed that failure to meet Patient's Charter targets should be placed in a statutory framework. If it had, it would have cost an awful lot of money.
	Meeting targets is best left to the performance management system of the health service. I am confident that the NHS will deliver on those targets. We as a Government will ensure that the NHS has the resources in terms of training places, money and facilities. I hope that on consideration the noble Baroness will agree that her amendment is not appropriate.

Baroness Noakes: I thank the Minister for that reply. He began by parading some successes of the NHS, as I would have expected. But the plain fact is that non-elective activity reduced last year and the number waiting more than 13 weeks rose by 27 per cent in the first nine months of this financial year. Things are not all moving in the direction of success.
	The Minister again says that the amendment is not appropriate. We are told to leave things to performance management, but I put it to the Minister that that is an internal perspective, whereas the amendment would put patients at the centre by firmly rooting a duty to deliver things for them, not considering internal management processes. I feel, as I did about the previous amendment, that the Government have a lot of rhetoric about wanting to meet targets. They have a whole structure based on the plan and its implementation. But when we ask them to put a little more commitment behind that in the form of a statutory commitment, we are told that that is inappropriate.
	I am disappointed. I shall reflect further. In the meantime, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.
	[Amendments Nos. 102 to 104 not moved.]

Lord Filkin: Now may be a convenient moment to end our consideration of the Bill in Committee today. I beg to move that the House do now resume.

Moved accordingly, and, on Question, Motion agreed to.
	House resumed.

Greenham and Crookham Commons Bill

Reported from the Unopposed Bill Committee with amendments.
	House adjourned at seventeen minutes before eleven o'clock.